What is the management approach for a patient with reduced ejection fraction?

Management of Heart Failure with Reduced Ejection Fraction

The cornerstone of management for patients with heart failure with reduced ejection fraction (HFrEF) is quadruple therapy with SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, which significantly reduces mortality and hospitalizations. 1

First-Line Pharmacological Therapy

Core Medications for HFrEF

1. SGLT2 Inhibitors

   • Start early as they have minimal impact on blood pressure
   • Can be used in patients with eGFR >20 ml/min/1.73m²
   • Recommended doses:
     • Dapagliflozin 10 mg once daily
     • Empagliflozin 10 mg once daily
   • Provide mortality benefit regardless of diabetes status 1

2. Renin-Angiotensin System Inhibitors

   • Sacubitril/Valsartan (ARNI) is preferred over ACE inhibitors for NYHA class II-III patients 1

     • Initial dose: 49/51 mg twice daily
     • Target dose: 97/103 mg twice daily
     • Monitor for hypotension as the most common side effect 2

   • ACE Inhibitors (if ARNI not tolerated or contraindicated)

     • Lisinopril: 2.5-5 mg once daily → 20-40 mg once daily
     • Enalapril: 2.5 mg twice daily → 10-20 mg twice daily
     • Ramipril: 1.25-2.5 mg once daily → 10 mg once daily

   • ARBs (if ACE inhibitors not tolerated)

     • Candesartan: 4-8 mg once daily → 32 mg once daily 3

3. Beta-Blockers

   • Start if heart rate >70 bpm
   • Consider selective β₁ receptor blockers in patients with low blood pressure
   • Recommended agents:
     • Bisoprolol: 1.25 mg once daily → 10 mg once daily
     • Carvedilol: 3.125 mg twice daily → 25-50 mg twice daily
     • Metoprolol succinate: 12.5-25 mg once daily → 200 mg once daily

4. Mineralocorticoid Receptor Antagonists (MRAs)

   • Have minimal impact on blood pressure
   • Monitor potassium and renal function
   • Options:
     • Spironolactone: 12.5-25 mg once daily → 25-50 mg once daily
     • Eplerenone: 25 mg once daily → 50 mg once daily 4
     • Particularly beneficial in post-MI HFrEF patients 4

Diuretics

• Adjust according to volume status
• Avoid overdiuresis which may lower blood pressure
• Use loop diuretics (e.g., furosemide) as first-line for congestion
• For refractory congestion, consider:
  • Higher doses of loop diuretics
  • Addition of a second diuretic (metolazone, spironolactone)
  • Continuous infusion of loop diuretic 5

Medication Titration Strategy

1. Initiate all four core medication classes as soon as possible 1
2. Up-titrate one drug at a time using small increments every 2-4 weeks 1
3. Follow a forced-titration strategy targeting maximum tolerated doses 1
4. Do not discontinue therapy prematurely due to asymptomatic changes in vital signs 1
5. For patients with low blood pressure:
   • Start with SGLT2 inhibitors and MRAs (minimal BP impact)
   • Use selective β₁ blockers if heart rate elevated
   • Consider more gradual up-titration and closer monitoring 5

Device Therapy Considerations

1. Implantable Cardioverter-Defibrillator (ICD)

   • Recommended for patients with LVEF ≤35% after ≥3 months of optimal medical therapy
   • Patient should have expected survival >1 year with good functional status 5
   • Not recommended for asymptomatic patients (NYHA class I) or those with preserved LVEF >40-45% 5

2. Cardiac Resynchronization Therapy (CRT)

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

Special Considerations

1. For patients who cannot tolerate beta-blockers:

   • Consider ivabradine for patients in sinus rhythm with HR >70 bpm 1

2. For patients with atrial fibrillation:

   • Consider digoxin for rate control if beta-blockers not tolerated 1

3. For patients with refractory heart failure:

   • Consider outpatient low-dose dobutamine infusion 5
   • Evaluate for heart transplantation in eligible patients 5

4. For patients recovering from acute HF with low BP:

   • Use more gradual up-titration protocol
   • Implement closer monitoring after discharge 5

5. For patients with HF and specific comorbidities:

   • Use multidisciplinary team approach for patients with:
     • Significant peripheral vascular disease
     • Bilateral carotid stenosis
     • Recent cerebrovascular events
     • End-stage renal disease on dialysis 5

Lifestyle Modifications and Patient Education

1. Physical Activity

   • Encourage regular, structured aerobic exercise starting with low intensity
   • Avoid heavy labor and isometric exercises 1

2. Dietary Recommendations

   • Implement moderate sodium restriction
   • Limit alcohol consumption to moderate intake (1-2 glasses of wine/day) 1

3. Self-Monitoring

   • Daily weight monitoring with action plan for weight gain >2 kg in 3 days
   • Regular assessment of volume status and symptoms 1

4. Patient Education

   • Provide comprehensive education on heart failure, symptom recognition, medication adherence
   • Ensure seamless transition of care from primary to tertiary levels 5

Medications to Avoid in HFrEF

1. NSAIDs and COX-2 inhibitors - increase risk of worsening heart failure 1
2. Thiazolidinediones (glitazones) - increase risk of worsening heart failure 1
3. Diltiazem/verapamil - increase risk of worsening heart failure 1
4. Combination of ARB with ACE inhibitor and MRA - increased risk of renal dysfunction and hyperkalemia 1

Monitoring Parameters

• Blood pressure and heart rate at each visit
• Serum electrolytes, urea nitrogen, and creatinine during active titration
• Daily weight monitoring by patient
• Clinical signs and symptoms of congestion
• For hyperkalemia (>5.5 mEq/L): reduce/temporarily discontinue RAAS inhibitors, intensify diuretic therapy if volume overloaded 1