Initial Treatment for HFrEF with LVEF of 35% According to AHA Guidelines
For patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and LVEF of 35%, the initial treatment should include triple neurohormonal blockade with an ACE inhibitor (or ARB if ACE inhibitor intolerant), beta-blocker, and mineralocorticoid receptor antagonist, along with diuretics for symptom relief. 1
First-Line Medications
1. ACE Inhibitors
- Class I, Level A recommendation 1
- Start with low dose and titrate up as tolerated
- Examples: lisinopril, enalapril, ramipril
- Contraindications: history of angioedema, bilateral renal artery stenosis, pregnancy
- Monitor: renal function, potassium levels 1-2 weeks after initiation
2. Beta Blockers
- Class I, Level A recommendation 1
- Use only the three beta blockers proven to reduce mortality:
- Bisoprolol
- Carvedilol
- Sustained-release metoprolol succinate
- Start at low dose and titrate gradually every 2 weeks as tolerated
- Target: maximum tolerated dose shown effective in clinical trials
- Can be safely initiated before hospital discharge if patient is clinically stable 1
3. Mineralocorticoid Receptor Antagonists (MRAs)
- Class I, Level A recommendation for NYHA class II-IV with LVEF ≤35% 1
- Options: spironolactone (12.5-25 mg daily) or eplerenone
- Monitoring requirements:
- Serum creatinine should be ≤2.5 mg/dL in men or ≤2.0 mg/dL in women
- Potassium should be <5.0 mEq/L
- Regular monitoring of renal function and electrolytes
4. Diuretics
- Class I, Level C recommendation for symptom relief in patients with fluid retention 1
- Loop diuretics (furosemide, torsemide, bumetanide) are first-line
- Initial dosing:
- Furosemide: 20-40 mg once or twice daily
- Bumetanide: 0.5-1.0 mg once or twice daily
- Torsemide: 10-20 mg once daily
- Adjust dose based on symptoms and volume status
Additional Therapies to Consider
1. Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
- Consider as replacement for ACE inhibitor in patients who remain symptomatic despite optimal therapy 2
- Requires 36-hour washout period when switching from ACE inhibitor
- Contraindicated in patients with history of angioedema
2. Ivabradine
- Consider for persistently symptomatic patients with:
- Sinus rhythm
- Heart rate ≥70 beats/min despite maximally tolerated beta-blocker dose
- LVEF ≤35% 1
3. Device Therapy
ICD for primary prevention is indicated for patients with:
- LVEF ≤35%
- NYHA class II-III symptoms on guideline-directed medical therapy 1
- Expected survival >1 year
Cardiac Resynchronization Therapy (CRT) is indicated for patients with:
- NYHA class II-IV symptoms
- LVEF ≤35%
- Left bundle branch block with QRS ≥150 ms 1
Treatment Algorithm
Initial Visit:
- Start ACE inhibitor (or ARB if intolerant) and beta-blocker simultaneously
- Add diuretics if fluid retention is present
- Educate patient on salt restriction and self-monitoring
Follow-up at 2 weeks:
- Check renal function and electrolytes
- Titrate medications as tolerated
- Add MRA if patient has LVEF ≤35% and remains symptomatic
Subsequent visits (every 2-4 weeks):
- Continue uptitration of medications to target doses
- Reassess symptoms and volume status
- Adjust diuretics based on symptoms and weight changes
After optimal medical therapy:
- Evaluate for device therapy (ICD, CRT) based on criteria
- Consider ARNI in patients who remain symptomatic
Common Pitfalls and Caveats
- Avoid calcium channel blockers with negative inotropic effects in HFrEF patients 1
- Avoid NSAIDs as they can worsen renal function and cause fluid retention
- Do not combine ACE inhibitors, ARBs, and aldosterone antagonists due to risk of hyperkalemia 1
- Do not abruptly withdraw beta-blocker therapy as it can lead to clinical deterioration 1
- Monitor potassium and renal function closely when using MRAs, especially in patients with diabetes or renal impairment
By following this comprehensive approach to HFrEF management with LVEF of 35%, clinicians can significantly reduce mortality, hospitalizations, and improve quality of life in these patients.