How do we improve ejection fraction in a patient with reduced ejection fraction?

Optimizing Ejection Fraction in Heart Failure with Reduced Ejection Fraction

To improve ejection fraction in a 68-year-old male with heart failure with reduced ejection fraction (HFrEF), implement a sequential medication approach starting with SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs), followed by beta-blockers and ARNI/ACEi/ARB therapy, with careful dose titration based on blood pressure tolerance. 1

Initial Medication Strategy

First-Line Agents (Minimal BP Impact)

1. SGLT2 Inhibitors

   • Start with dapagliflozin 10 mg daily or empagliflozin 10 mg daily
   • Can be initiated even with low blood pressure
   • Provides rapid beneficial effects on heart failure outcomes 1, 2

2. Mineralocorticoid Receptor Antagonists (MRAs)

   • Start with spironolactone 12.5-25 mg daily or eplerenone 25 mg daily
   • Target dose: spironolactone 25-50 mg daily or eplerenone 50 mg daily
   • Minimal effect on blood pressure while providing mortality benefit 1, 2

Second-Line Agents (Moderate BP Impact)

1. Beta-Blockers

   • If heart rate >70 bpm, initiate selective β₁ receptor blockers:
     • Bisoprolol 1.25 mg daily (target: 10 mg daily) OR
     • Metoprolol succinate 12.5-25 mg daily (target: 200 mg daily)
   • Selective β₁ blockers preferred over non-selective agents like carvedilol due to lesser BP-lowering effect 1
   • Beta-blockers have demonstrated consistent improvement in ejection fraction across multiple studies 3

2. Alternative for Heart Rate Control

   • If beta-blockers are not tolerated:
     • Ivabradine 2.5-5 mg twice daily (for patients in sinus rhythm with HR >70 bpm)
     • Can be used alone or with low-dose beta-blockers to facilitate their titration 1, 4

Third-Line Agents (Greater BP Impact)

1. ARNI/ACEi/ARB
   • Start with very low dose sacubitril/valsartan (25 mg twice daily)
   • Gradually increase to target dose (97/103 mg twice daily) if tolerated
   • If sacubitril/valsartan not tolerated, use low-dose ACE inhibitor or ARB 1, 2

Titration Strategy

1. Sequential Approach

   • Initiate or up-titrate one drug at a time using small increments
   • Allow 1-2 weeks between dose adjustments
   • Continue until highest tolerated or target dose of each medication is achieved 1

2. Monitoring Parameters

   • Blood pressure (supine and standing)
   • Heart rate
   • Renal function
   • Electrolytes (particularly potassium)
   • Symptoms of heart failure 1

3. Diuretic Management

   • Adjust diuretics according to volume status
   • Avoid overdiuresis which may result in lower BP
   • Consider reducing diuretic dose if patient develops hypotension 1

Device Therapy Considerations

1. Cardiac Resynchronization Therapy (CRT)

   • Consider for patients with QRS duration ≥150 msec and LBBB morphology
   • Can significantly improve ejection fraction in appropriate candidates 1, 2

2. Implantable Cardioverter-Defibrillator (ICD)

   • Consider for patients with LVEF ≤35% despite ≥3 months of optimal medical therapy
   • Provides mortality benefit in addition to medication therapy 2

Common Pitfalls and Caveats

1. Blood Pressure Management

   • Low BP should not automatically preclude guideline-directed medical therapy
   • Asymptomatic low BP can often be managed without reducing medications
   • For symptomatic hypotension, consider spacing out medications throughout the day 1

2. Beta-Blocker Selection

   • Selective β₁ blockers (bisoprolol, metoprolol) may be better tolerated in patients with low BP
   • Non-selective beta-blockers with α, β₁, and β₂-blocking properties have greater BP-lowering effects 1
   • All beta-blockers appear to improve ejection fraction, with average increases of 4.6-8.6 EF units 3

3. Medication Interactions

   • Avoid combining ARB with ACE inhibitor and MRA due to increased risk of renal dysfunction and hyperkalemia 2
   • Avoid medications that can worsen heart failure (NSAIDs, non-dihydropyridine calcium channel blockers) 2

By implementing this structured approach to medication initiation and titration, ejection fraction can be improved while minimizing the risk of adverse effects related to hypotension. Close monitoring and gradual dose adjustments are essential to achieve optimal outcomes in this 68-year-old male with HFrEF.