What is the treatment for a patient with severely reduced left ventricular systolic function and a left ventricular ejection fraction of 20-25%?

Treatment for Severely Reduced Left Ventricular Systolic Function with LVEF 20-25%

Patients with severely reduced left ventricular systolic function (LVEF 20-25%) should receive quadruple therapy consisting of an ACE inhibitor (or ARB/ARNI), beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor as the cornerstone of treatment to reduce mortality and hospitalizations. 1

First-Line Pharmacological Therapy

1. ACE Inhibitors/ARBs/ARNIs

• Start with ACE inhibitor (Class I recommendation) 2
  • Lisinopril (target: 20-40 mg daily)
  • Enalapril (target: 10-20 mg twice daily)
  • Ramipril (target: 10 mg daily)
• If ACE inhibitor not tolerated, use ARB 2, 1
  • Candesartan (target: 32 mg daily)
  • Valsartan (target: 160 mg twice daily)
• Consider upgrading to ARNI (sacubitril/valsartan) 1, 3
  • Start at 49/51 mg twice daily
  • Target dose: 97/103 mg twice daily
  • Shown superior to enalapril in reducing cardiovascular death and HF hospitalization (HR 0.8) 3

2. Beta-Blockers

• Use evidence-based beta-blockers only 2, 1:
  • Carvedilol (target: 25 mg twice daily)
  • Metoprolol succinate (target: 200 mg daily)
  • Bisoprolol (target: 10 mg daily)
• Start at low dose and titrate every 2 weeks as tolerated 1

3. Mineralocorticoid Receptor Antagonists

• Spironolactone 12.5-50 mg daily (particularly for NYHA class III-IV) 2, 1
• Eplerenone 50 mg daily (alternative option) 1
• Monitor potassium and renal function closely 2

4. SGLT2 Inhibitors

• Dapagliflozin 10 mg daily or Empagliflozin 10 mg daily 1
• Can be started early in treatment due to minimal effect on blood pressure 1
• Reduces hospitalization and cardiovascular death 1

Diuretic Therapy for Symptom Management

• Diuretics for fluid overload (Class I recommendation) 2
• Adjust dose based on symptoms and signs of congestion 1
• For refractory cases, consider:
  • Changing from oral to IV diuretics 2
  • Short periods of bed rest 2
  • Combination diuretic strategies

Advanced Therapies for Severely Reduced LVEF

Device Therapy

• Implantable cardioverter-defibrillator (ICD) for patients with LVEF ≤35% 2, 1
• Cardiac resynchronization therapy (CRT) for patients with LVEF ≤35% and QRS ≥150ms 2, 1
• Consider mechanical circulatory support for end-stage disease 1

Additional Pharmacological Options

• Ivabradine for patients in sinus rhythm with heart rate ≥70 bpm despite beta-blockers 1
• For self-identified African American patients, consider hydralazine and isosorbide dinitrate combination 2, 1
• Low-dose dobutamine (2-5 μg/kg/min) may be considered for refractory heart failure (Class II recommendation) 2

Lifestyle Modifications

• Regular aerobic exercise (walking, biking) to improve functional capacity 2, 1
• Avoid isometric exercise (weightlifting) 2
• Daily weight monitoring with instructions to adjust diuretics if weight increases by 1.5-2.0 kg over 2 days 1
• Sodium and fluid restriction 1

Treatment Pitfalls to Avoid

1. Underutilization of guideline-directed therapy - Only 1% of eligible patients receive target doses of all recommended medications 4
2. Excessive concern about low blood pressure - Should not prevent initiation or uptitration of therapy 1
3. Inappropriate discontinuation of medications during hospitalization 1
4. Failure to consider heart transplantation for refractory cases 2
5. Calcium channel blockers - Avoid in the absence of coexistent angina or hypertension (Class III recommendation) 2

Monitoring and Follow-up

• Monitor renal function and electrolytes, especially when using ACE inhibitors, ARBs, ARNIs, and MRAs 2, 1
• Consider specialist monitoring of serum natriuretic peptide levels in selected patients 2
• Provide comprehensive patient education on self-monitoring, salt restriction, and fluid management 1

End-Stage Management

• Consider heart transplantation for refractory heart failure 2
• Mechanical ventricular assist devices for bridge to transplant or destination therapy 2, 1
• Continuous intravenous positive inotropic therapy for symptom management in end-stage disease 2, 1
• Palliative care including symptom relief with opiates for end-stage disease 1

The evidence strongly supports implementing all four pillars of guideline-directed medical therapy (ACEI/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors) as soon as possible to achieve the greatest reduction in mortality and hospitalization for patients with severely reduced ejection fraction.