What is the management for a patient with an ejection fraction (EF) of 40%?

Management of Heart Failure with Ejection Fraction of 40%

For a patient with an ejection fraction (EF) of 40%, guideline-directed medical therapy should include an ACE inhibitor (or ARB), beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor as these medications reduce mortality, hospitalizations, and improve quality of life. 1

Classification of the Patient

An ejection fraction of 40% places this patient in the category of heart failure with reduced ejection fraction (HFrEF), as defined by the 2022 AHA/ACC/HFSA guidelines which classify HFrEF as LVEF ≤40% 1. This classification is important because it determines the evidence-based treatment approach.

First-Line Pharmacological Therapy

Core Medications (All Should Be Prescribed)

1. ACE Inhibitors or ARBs

   • Start and continue indefinitely in all patients with LVEF ≤40% 1
   • Target maximum tolerated doses
   • Consider switching to an ARNI (sacubitril/valsartan) in patients who remain symptomatic despite optimal therapy

2. Beta-Blockers

   • Start and continue indefinitely in all patients who have had myocardial infarction, acute coronary syndrome, or left ventricular dysfunction 1
   • Use metoprolol succinate, carvedilol, or bisoprolol (evidence-based options)
   • Start at low doses and titrate gradually every 2 weeks to target doses 2

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Eplerenone or spironolactone is recommended for patients with an EF ≤40% 1, 3
   • Spironolactone has been shown to reduce the risk of death by 30% in patients with HFrEF 3
   • Monitor potassium and renal function regularly

4. SGLT2 Inhibitors

   • Recommended for patients with HFrEF to reduce heart failure hospitalizations and cardiovascular death 1
   • Can be used regardless of diabetes status

Additional Pharmacological Therapy

1. Diuretics

   • Use for symptom relief in patients with evidence of fluid overload 1
   • Adjust dosage to maintain euvolemia while minimizing adverse effects
   • Loop diuretics are preferred over thiazides for most HFrEF patients

2. Ivabradine

   • Consider for patients with persistent heart rate >70 bpm despite maximally tolerated beta-blocker doses

Special Considerations

Atrial Fibrillation

If the patient has atrial fibrillation:

• Anticoagulate if no contraindications 1
• Control ventricular rate with beta-blockers or digoxin 1
• Consider electrical or pharmacological cardioversion in appropriate candidates 1

Coronary Artery Disease

If the patient has underlying coronary artery disease:

• Consider antiplatelet therapy 1
• Evaluate for revascularization if appropriate
• Optimize lipid management

Monitoring and Follow-up

1. Regular Assessment

   • Monitor symptoms, vital signs, weight, and volume status
   • Perform laboratory tests to assess electrolytes and renal function, especially after medication changes

2. Serial Echocardiography

   • Follow LVEF over time to assess for improvement
   • If LVEF improves to >40%, the patient would be reclassified as having HF with improved EF (HFimpEF) but should continue HFrEF treatment 1

Common Pitfalls to Avoid

1. Inadequate Dosing

   • Many patients receive suboptimal doses of medications
   • Aim for target doses or maximum tolerated doses of all medications

2. Premature Discontinuation

   • Do not discontinue beta-blockers abruptly due to risk of rebound ischemia or arrhythmias 2
   • Continue guideline-directed medical therapy even if symptoms improve or LVEF normalizes

3. Inadequate Monitoring

   • Failure to monitor electrolytes and renal function can lead to complications
   • Regular assessment of potassium is particularly important with ACE inhibitors and MRAs

4. Neglecting Comorbidities

   • Address hypertension, diabetes, and other conditions that may worsen heart failure

Treatment Algorithm

1. Initial Assessment

   • Confirm diagnosis and EF measurement
   • Evaluate for underlying causes and comorbidities

2. Start Core Medications

   • Begin ACE inhibitor/ARB and beta-blocker simultaneously at low doses
   • Add MRA if patient remains symptomatic or has LVEF ≤40%
   • Add SGLT2 inhibitor
   • Add diuretics as needed for congestion

3. Titration Phase

   • Gradually increase doses of core medications every 2-4 weeks as tolerated
   • Monitor blood pressure, heart rate, renal function, and electrolytes

4. Maintenance Phase

   • Continue maximum tolerated doses of all medications
   • Regular follow-up to assess symptoms and adjust therapy as needed
   • Consider device therapy (ICD/CRT) if LVEF remains ≤35% despite optimal medical therapy

This comprehensive approach to managing heart failure with an ejection fraction of 40% focuses on evidence-based therapies that have been shown to reduce mortality and improve quality of life.