What is the prognosis and management for a patient with a severely reduced ejection fraction (EF) of 15%?

Prognosis and Management of Severely Reduced Ejection Fraction (EF) of 15%

Patients with a severely reduced ejection fraction of 15% have a high mortality rate of approximately 74% at three years, requiring aggressive guideline-directed medical therapy (GDMT) and consideration for device therapy to improve survival.

Prognosis

• When ejection fraction is ≤20%, the 3-year mortality rate is approximately 74%, with peak VO₂ being a stronger predictor of outcomes than the specific EF value 1
• Once EF falls below 20%, small differences in EF (such as between 10% and 20%) are no longer significant predictors of mortality 1
• Patients with severely reduced EF have high risk for:
  • Sudden cardiac death due to ventricular arrhythmias 2
  • Progressive heart failure symptoms and hospitalizations 2
  • Poor quality of life due to symptoms of congestion and low cardiac output 2

Management Approach

Pharmacological Therapy

1. First-line medications (should be initiated and optimized in all eligible patients):

   • ACE inhibitors or ARBs to reduce mortality and hospitalization risk 2, 3
   • Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) to reduce mortality by at least 20% and decrease risk of sudden death 2, 4
   • Mineralocorticoid receptor antagonists (MRAs) to reduce mortality and sudden death risk by 23% 2
   • SGLT2 inhibitors (dapagliflozin or empagliflozin) to reduce heart failure hospitalization and death 2

2. Additional medications based on clinical status:

   • Sacubitril/valsartan to replace ACE inhibitor/ARB in patients who remain symptomatic, reducing hospitalization and death risk 2
   • Diuretics for symptom relief in patients with signs/symptoms of congestion 2, 5
   • Consider digoxin for symptom control in patients with persistent symptoms despite optimal therapy 2

Device Therapy

• ICD implantation is strongly recommended for patients with EF ≤35% despite ≥3 months of optimal medical therapy, expected survival >1 year with good functional status 2
• Cardiac Resynchronization Therapy (CRT) should be considered for patients with:
  • Symptomatic HF with sinus rhythm
  • LVEF ≤35% despite GDMT
  • QRS duration ≥150 ms with LBBB QRS morphology 2
• Heart transplantation evaluation should be considered given the extremely low EF and associated poor prognosis 2

Management of Low Blood Pressure

• Low blood pressure is a common barrier to optimal GDMT implementation but should not automatically prevent medication use 2
• For patients with symptomatic low BP or SBP <80 mmHg:
  • Identify and treat reversible non-HF causes of hypotension
  • Consider temporary reduction of non-HF medications that lower BP 2
  • Prioritize medications with proven mortality benefit (beta-blockers, ACE inhibitors/ARBs, MRAs) even at lower doses 2

Multidisciplinary Care

• Enrollment in a multidisciplinary heart failure management program is recommended to reduce hospitalization risk and improve survival 2
• Regular monitoring of:
  • Symptoms and signs of congestion
  • Renal function and electrolytes
  • Medication adherence and side effects 2

Special Considerations

• Coronary artery disease: If obstructive CAD is suspected in patients with EF ≤35%, invasive coronary angiography is recommended with consideration for revascularization 2
• Valvular heart disease: Evaluate for significant valvular disease that may contribute to or exacerbate heart failure 2
• Arrhythmias: Aggressive management of atrial fibrillation and ventricular arrhythmias is essential 2

Common Pitfalls to Avoid

• Underutilization of GDMT: Despite proven benefits, many patients with severely reduced EF do not receive optimal medical therapy 2
• Premature discontinuation of medications due to low BP: Even with low BP, mortality benefits of GDMT often outweigh risks 2
• Delayed referral for device therapy: Timely evaluation for ICD/CRT is crucial for mortality reduction 2
• Inadequate diuresis: Proper volume management is essential for symptom control and to allow uptitration of disease-modifying therapies 2
• Failure to recognize need for advanced therapies: Patients with EF as low as 15% may need early evaluation for advanced heart failure therapies including mechanical circulatory support or transplantation 2

By implementing comprehensive GDMT, appropriate device therapy, and multidisciplinary care, the poor prognosis associated with severely reduced EF can be improved, though close monitoring and consideration for advanced therapies remain essential components of management.