What is the recommended treatment for a patient with heart failure with reduced ejection fraction (HFrEF) and diastolic dysfunction, with a left ventricular ejection fraction of 40-45% and Grade II diastolic dysfunction?

Treatment for Heart Failure with Mildly Reduced Ejection Fraction and Grade II Diastolic Dysfunction

Patients with heart failure with mildly reduced ejection fraction (HFmrEF) with LVEF 40-45% and Grade II diastolic dysfunction should be treated with guideline-directed medical therapy (GDMT) including ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors to reduce mortality and hospitalizations.

Classification and Understanding of the Patient's Condition

This patient has:

• LVEF of 40-45%, classifying them as having HFmrEF according to the 2022 AHA/ACC/HFSA guidelines 1
• Grade II diastolic dysfunction (pseudonormalization pattern)
• Regional wall motion abnormalities (moderate hypokinesis in mid inferoseptal and apical septal walls; mild hypokinesis in mid anterior and apical anterior walls)

Recommended Treatment Algorithm

First-Line Therapies (Class I recommendations)

1. ACE inhibitors or ARBs

   • Start at low dose and titrate to target doses proven in clinical trials
   • Monitor renal function and electrolytes 1-2 weeks after each dose increase 2

2. Beta-blockers

   • Only three have proven mortality benefit: bisoprolol, carvedilol, and sustained-release metoprolol succinate
   • Start at low dose and gradually uptitrate 2

3. Diuretics

   • Loop diuretics (furosemide, bumetanide, torsemide) for symptom relief and volume management
   • Adjust dose based on symptoms and signs of congestion 1, 2

Second-Line Therapies (Class IIa recommendations)

1. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone or eplerenone
   • Particularly beneficial for patients with LVEF ≤35%, but also recommended for HFmrEF
   • Monitor potassium and renal function carefully 1

2. SGLT2 inhibitors (dapagliflozin or empagliflozin)

   • Add to reduce mortality and hospitalization
   • Monitor electrolytes and renal function 2

3. Angiotensin Receptor-Neprilysin Inhibitor (ARNI)

   • Consider switching from ACE inhibitor to sacubitril/valsartan
   • Shown to be superior to enalapril in reducing cardiovascular death and heart failure hospitalization 3

Special Considerations for Diastolic Dysfunction

For the Grade II diastolic dysfunction component:

• Optimize volume status with careful diuretic use
• Control blood pressure to reduce LV filling pressures
• Control heart rate to optimize diastolic filling time 1
• Address myocardial ischemia if present, given the regional wall motion abnormalities 1

Device Therapy Considerations

• Implantable Cardioverter-Defibrillator (ICD) should be considered if LVEF remains ≤35% despite 3 months of optimal medical therapy
• Cardiac Resynchronization Therapy (CRT) if QRS ≥150ms with LBBB morphology 2

Monitoring and Follow-up

1. Monitor serum electrolytes, BUN, and creatinine during treatment
2. Assess daily weight, urine output, and volume status
3. Follow-up echocardiography in 3-6 months to assess response to therapy
4. Regular assessment of symptoms, vital signs, and volume status 2

Lifestyle Modifications

1. Sodium restriction (moderate)
2. Regular aerobic exercise as tolerated
3. Alcohol limitation
4. Daily weight monitoring with instructions to increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days
5. Smoking cessation if applicable 2

Important Clinical Pearls and Pitfalls

1. Patients with improved LVEF (previously <40% now 40-45%) should continue their HFrEF treatment regimen to prevent relapse 1
2. Avoid rapid correction of hyponatremia, NSAIDs, and excessive diuresis, which can worsen renal function and fluid retention 2
3. The pseudonormalization pattern (Grade II diastolic dysfunction) indicates more advanced diastolic dysfunction than Grade I and requires careful management of filling pressures
4. Regional wall motion abnormalities suggest possible underlying coronary artery disease that may require evaluation and treatment 1
5. Combination therapy requires careful monitoring of electrolytes and renal function 2

By following this comprehensive treatment approach targeting both systolic and diastolic dysfunction, the patient's symptoms, quality of life, and prognosis can be significantly improved.