What is the recommended treatment for a patient with a reduced ejection fraction (EF) of 40-45% and left ventricular outflow tract velocity time integral (LVOT VTI) of 11.1?

Treatment for Heart Failure with Mildly Reduced Ejection Fraction (EF 40-45%)

For a patient with an ejection fraction of 40-45% and LVOT VTI of 11.1, the recommended treatment includes an ACE inhibitor (or ARB), beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor to reduce mortality, hospitalizations, and improve quality of life. 1

Classification and Treatment Framework

This patient falls into the category of Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF) according to the 2022 AHA/ACC/HFSA guidelines, which define HFmrEF as an LVEF of 41-49% 1. The low LVOT VTI of 11.1 indicates reduced stroke volume, supporting the diagnosis of heart failure with compromised cardiac output.

Core Medication Therapy

1. ACE Inhibitor or ARB

   • Start with low-dose Enalapril 2.5 mg twice daily, titrating to 10-20 mg twice daily 2
   • Alternative: Valsartan 40 mg twice daily, titrating to 160 mg twice daily
   • Monitor renal function and potassium levels before initiation, 1-2 weeks after dose increases, and every 3-6 months during maintenance 2

2. Beta-Blocker

   • Metoprolol succinate: Start at 12.5-25 mg daily, titrate to target dose of 200 mg daily 2, 3
   • Alternative: Carvedilol 3.125 mg twice daily, titrate to 25 mg twice daily (if <85 kg) or 50 mg twice daily (if ≥85 kg) 2, 4
   • Titrate by doubling the dose every 2 weeks as tolerated

3. Mineralocorticoid Receptor Antagonist (MRA)

   • Spironolactone 12.5-25 mg daily, titrate to 25-50 mg daily 2
   • Alternative: Eplerenone 25 mg daily, titrate to 50 mg daily
   • Monitor potassium and renal function closely

4. SGLT2 Inhibitor

   • Dapagliflozin 10 mg daily or Empagliflozin 10 mg daily 2
   • Add after stabilization on other medications

Titration and Monitoring Strategy

1. Initial Phase (0-4 weeks)

   • Begin ACE inhibitor/ARB and beta-blocker simultaneously
   • Schedule follow-up at 2 weeks to assess tolerance and begin titration
   • Monitor blood pressure, heart rate, renal function, and electrolytes

2. Optimization Phase (1-3 months)

   • Add MRA after patient is stable on ACE inhibitor/ARB and beta-blocker
   • Continue uptitration of all medications every 2 weeks as tolerated
   • Add SGLT2 inhibitor after stabilization on other medications

3. Maintenance Phase

   • Aim to reach target doses of all medications within 3-6 months
   • Schedule echocardiography at 3-6 months to assess improvement in EF
   • Continue monitoring for side effects and adjust as needed

Special Considerations

• Low LVOT VTI: The LVOT VTI of 11.1 indicates reduced stroke volume, which may be improved with optimal medical therapy. Normal LVOT VTI is typically >18-20 cm 1

• Potential for EF Improvement: Patients with HFmrEF may improve their EF with optimal medical therapy. The 2022 guidelines classify patients who improve from HFrEF to EF >40% as HFimpEF (HF with improved EF) and recommend continuing HFrEF treatment 1

• Diuretic Therapy: Low-dose loop diuretics should be considered for symptomatic patients to manage congestion, but they do not improve mortality 1

• Device Therapy Evaluation: If EF remains ≤35% despite 3-6 months of optimal medical therapy, evaluate for device therapy (ICD/CRT) 2

Common Pitfalls to Avoid

1. Underutilization of GDMT: Studies show that while most patients receive beta-blockers and ACE inhibitors/ARBs, MRAs and SGLT2 inhibitors are often underutilized despite their mortality benefit 5, 6

2. Inadequate Titration: Many patients remain on suboptimal doses. Aim for target doses shown to reduce mortality in clinical trials 7

3. Premature Discontinuation: Avoid discontinuing medications during hospitalization for acute decompensation, as this leads to higher mortality and readmission rates 8

4. Excessive Concern About Hypotension: Low blood pressure should not prevent uptitration if the patient is asymptomatic 2

5. Delayed Optimization: Early initiation and optimization of all four medication classes leads to better outcomes 8

By implementing this comprehensive treatment approach, you can maximize the chance of improving cardiac function, reducing symptoms, and decreasing mortality in this patient with HFmrEF.