Optimal Management for 70-Year-Old Male with HFrEF, LVEF <25%, and Persistent Atrial Fibrillation
The patient should continue all four pillars of guideline-directed medical therapy (GDMT) for HFrEF and undergo implantable cardioverter-defibrillator (ICD) placement for primary prevention of sudden cardiac death, given his severely reduced ejection fraction that has persisted despite optimal medical therapy. 1
Current Medication Assessment
The patient is currently on all four pillars of GDMT for HFrEF:
- Beta-blocker: Metoprolol succinate
- SGLT2 inhibitor: Jardiance (empagliflozin)
- ARNI: Entresto (sacubitril/valsartan) - recently increased to 49-51 mg twice daily
- MRA: Spironolactone
- Anticoagulation: Eliquis for atrial fibrillation
This medication regimen aligns with Class I recommendations from the 2022 AHA/ACC/HFSA guidelines for HFrEF management 1, 2.
Management Priorities
1. Optimize GDMT
- Continue titrating Entresto to target dose of 97/103 mg twice daily as tolerated 3
- Ensure metoprolol succinate is at target dose (200 mg daily) 2
- Maintain spironolactone at 25-50 mg daily with appropriate monitoring of renal function and potassium 1, 2
- Continue Jardiance (empagliflozin) as it provides mortality benefit independent of diabetes status 2
2. ICD Placement Decision
- Primary prevention ICD is strongly indicated (Class I recommendation) for this patient with:
- LVEF <25% (severely reduced)
- Optimal medical therapy for several years
- Persistent reduction in EF despite GDMT 1
- Dilated cardiomyopathy
- Symptoms of functional limitation (unable to walk 100-200 feet without resting)
The patient's hesitancy about ICD placement should be addressed, but the mortality benefit is substantial in his case. His LVEF has remained severely reduced (<25%) despite years of heart failure treatment, making him an ideal candidate for primary prevention ICD 1.
3. Rate Control for Atrial Fibrillation
- Continue metoprolol for rate control of atrial fibrillation
- Avoid calcium channel blockers like diltiazem or verapamil due to negative inotropic effects in HFrEF (Class III: Harm) 1, 4
4. Ischemic Evaluation
- Given the fixed apical defect on nuclear stress test and global hypokinesis, coronary evaluation is reasonable (Class IIa) 1
- Consider pursuing the previously planned coronary CT angiography with heart flow to evaluate for obstructive CAD
Special Considerations
Rhythm Control vs. Rate Control
- The patient declined cardioversion after initially agreeing to it
- Rate control with metoprolol is an acceptable strategy for persistent atrial fibrillation in HFrEF 1
- If pursuing rhythm control in the future, amiodarone would be appropriate for cardioversion
Potential for LVEF Improvement with GDMT
- Recent evidence suggests that sacubitril/valsartan (Entresto) can induce beneficial cardiac remodeling, potentially improving LVEF 5, 6
- In one study, 40% of patients previously eligible for ICD were no longer eligible after treatment with sacubitril/valsartan 5
- However, this patient has had HFrEF for 10-15 years with persistently low EF despite years of beta-blocker and SGLT2i therapy
- The likelihood of significant LVEF improvement to >35% is low given his long-standing disease and already being on multiple GDMT components
Follow-up Plan
- Complete the planned echocardiogram in 5 weeks
- If LVEF remains ≤35% (which is likely given his history), proceed with ICD placement
- Continue to titrate Entresto to target dose as tolerated
- Consider coronary evaluation to rule out ischemic etiology contributing to HF
- Maintain anticoagulation with Eliquis for stroke prevention in atrial fibrillation
Pitfalls to Avoid
- Delaying ICD placement indefinitely in a high-risk patient with LVEF <25%
- Discontinuing beta-blockers due to fatigue or other symptoms
- Inadequate monitoring of renal function and potassium with MRA therapy
- Attempting to use calcium channel blockers for rate control in HFrEF
- Underestimating the risk of sudden cardiac death in a patient with severely reduced EF
This patient's functional decline (inability to walk more than 100-200 feet without resting) despite optimal medical therapy further emphasizes the need for aggressive management, including serious consideration of ICD placement for primary prevention of sudden cardiac death.