What is the recommended treatment plan for a patient with an ejection fraction (EF) of 50-55%, mild mitral regurgitation, mild tricuspid regurgitation, and Grade II diastolic dysfunction?

Treatment Plan for Patient with EF 50-55%, Mild Mitral and Tricuspid Regurgitation, and Grade II Diastolic Dysfunction

The recommended treatment plan for this patient should focus on guideline-directed medical therapy (GDMT) with ACE inhibitors/ARBs or ARNI, beta-blockers, MRAs, and SGLT2 inhibitors, as these medications have demonstrated mortality and morbidity benefits even in patients with preserved ejection fraction and valvular abnormalities.

Understanding the Patient's Condition

This patient presents with:

• Normal left ventricular size, thickness, and function
• Preserved ejection fraction (EF 50-55%)
• Mild mitral regurgitation
• Mild tricuspid regurgitation
• Grade II diastolic dysfunction (pseudonormalization pattern)

This clinical picture represents heart failure with preserved ejection fraction (HFpEF) with valvular involvement and diastolic dysfunction.

Core Treatment Components

1. Pharmacological Management

First-Line Medications

• SGLT2 Inhibitors: Start with empagliflozin 10mg daily or dapagliflozin 10mg daily
  • These medications have shown significant benefits in reducing heart failure hospitalizations regardless of diabetic status 1
  • They have minimal impact on blood pressure, making them ideal first choices

Additional Core Medications

• ACE Inhibitors/ARBs or ARNI:

  • Consider starting with low dose sacubitril/valsartan 24/26mg BID and titrating to target dose of 97/103mg BID 1, 2
  • Alternative: Start with enalapril 2.5mg BID and titrate to 10-20mg BID
  • These medications have shown benefits in patients with HFpEF, particularly those with LVEF below normal 2

• Beta-Blockers:

  • Start with low dose (e.g., metoprolol succinate 12.5-25mg daily, carvedilol 3.125mg BID, or bisoprolol 1.25mg daily) 1
  • Titrate gradually to target doses (metoprolol succinate 200mg daily, carvedilol 25-50mg BID based on weight, or bisoprolol 10mg daily)
  • Each mg equivalent of bisoprolol has been associated with incremental reductions in mortality risk in patients with mildly reduced EF 3

• Mineralocorticoid Receptor Antagonists (MRAs):

  • Start with spironolactone 12.5-25mg daily or eplerenone 25mg daily 1
  • Target dose: spironolactone 25-50mg daily or eplerenone 50mg daily
  • Monitor renal function and potassium before and 1-2 weeks after dose adjustment 1

2. Management of Valvular Regurgitation

• For mild mitral and tricuspid regurgitation:
  • Medical therapy is the mainstay of treatment
  • Functional tricuspid regurgitation (FTR) is independently associated with worse outcomes in heart failure patients, with 5-year survival rates of 58±2% for mild FTR 4
  • Optimize GDMT to reduce left ventricular filling pressures and pulmonary pressures, which can improve functional regurgitation

3. Management of Diastolic Dysfunction

• For Grade II diastolic dysfunction:
  • Focus on blood pressure control and volume management
  • SGLT2 inhibitors can help with volume status without significantly affecting blood pressure 1
  • Beta-blockers help by slowing heart rate, allowing more time for ventricular filling
  • ACE inhibitors/ARBs or ARNI help reduce afterload and promote favorable remodeling

Implementation Strategy

1. Initiation Phase:

   • Start with SGLT2 inhibitor and MRA as they have minimal impact on blood pressure 1
   • After 1-2 weeks, add beta-blocker at low dose if heart rate >70 bpm
   • After another 1-2 weeks, add ACE inhibitor/ARB or ARNI at low dose

2. Titration Phase:

   • Titrate one medication at a time using small increments every 1-2 weeks 1
   • Monitor vital signs, volume status, renal function, and electrolytes regularly
   • Target the highest tolerated or recommended doses of each medication

3. Monitoring Plan:

   • Check renal function and potassium before and 1-2 weeks after starting or adjusting MRAs 1
   • Schedule follow-up visits every 1-2 weeks during initial titration
   • Monitor for symptomatic hypotension, but do not discontinue medications for mild asymptomatic hypotension 1

Important Considerations and Pitfalls

• Do not undertreate due to fear of side effects: The benefits of GDMT outweigh the risks of adverse events in most patients 1

• Spacing medications: If hypotension occurs, space out medications to reduce synergistic hypotensive effects 1

• Contraindications to watch for:

  • ACE inhibitors/ARBs/ARNI: severe renal impairment, hyperkalemia, history of angioedema
  • Beta-blockers: severe bradycardia, hypotension, decompensated heart failure
  • MRAs: severe renal dysfunction, hyperkalemia
  • SGLT2 inhibitors: eGFR <30 mL/min/1.73m²

• Washout period: If transitioning from ACE inhibitor to ARNI, ensure a 36-hour washout period 1

By following this comprehensive treatment plan, you can effectively manage this patient's condition, potentially improving symptoms, quality of life, and long-term outcomes.