From the Guidelines
For a patient with an LVEF of 45%, I strongly recommend initiating treatment with an ACE inhibitor, such as lisinopril 2.5-5 mg once daily, titrated to a target dose of 20-40 mg once daily, or an ARB, such as losartan 25-50 mg once daily, titrated to a target dose of 50-150 mg once daily, as first-line therapy, as supported by the 2022 AHA/ACC/HFSA guideline 1.
Medication Recommendations
- An ACE inhibitor or ARB should be started as first-line therapy to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 1.
- A beta-blocker, such as bisoprolol 1.25 mg once daily, titrated to a target dose of 10 mg once daily, or carvedilol 3.125 mg twice daily, titrated to a target dose of 25-50 mg twice daily, should also be initiated to further reduce morbidity and mortality 1.
- Consider adding a mineralocorticoid receptor antagonist, such as spironolactone 12.5-25 mg once daily, titrated to a target dose of 25-50 mg once daily, especially if symptoms persist, as it has been shown to provide additional benefit in patients with HFrEF 1.
- For patients with persistent symptoms, an SGLT2 inhibitor, such as dapagliflozin 10 mg once daily, can provide additional benefit and should be considered as part of the treatment regimen 1.
Dosing and Titration
- Start with lower doses and titrate upward while monitoring blood pressure, renal function, and electrolytes to minimize adverse effects and ensure medication tolerance.
- Regular follow-up every 2-4 weeks during dose adjustments is essential to ensure medication effectiveness and adjust the treatment plan as needed.
Rationale
- The recommended medications work by reducing cardiac workload, preventing adverse remodeling, and improving cardiac efficiency, ultimately leading to improved morbidity, mortality, and quality of life outcomes in patients with HFrEF 1.
- The 2022 AHA/ACC/HFSA guideline provides the most recent and highest quality evidence for the management of heart failure, and its recommendations should be followed to ensure optimal patient outcomes 1.
From the FDA Drug Label
The mean left ventricular ejection fraction was 29%. Efficacy of sacubitril and valsartan was evaluated in a multinational, randomized, double-blind trial PANORAMA-HF comparing sacubitril and valsartan (n = 187) and enalapril (n = 188) in pediatric patients aged 1 month to less than 18 years old due to systemic left ventricular systolic dysfunction (LVEF ≤ 45% or fractional shortening ≤ 22. 5%). Carvedilol Tablet is indicated to reduce cardiovascular mortality in clinically stable patients who have survived the acute phase of a myocardial infarction and have a left ventricular ejection fraction of less than or equal to 40% (with or without symptomatic heart failure)
Recommended medications for a patient with a Left Ventricular Ejection Fraction (LVEF) of 45% may include:
- Sacubitril and valsartan 2, as it has been evaluated in patients with LVEF ≤ 45%
- Carvedilol 3 3, as it is indicated for patients with LVEF ≤ 40% These medications may be used to reduce the risk of cardiovascular mortality and hospitalization for heart failure. However, the specific treatment should be determined by a healthcare professional based on individual patient needs and medical history.
From the Research
Medications for Left Ventricular Ejection Fraction (LVEF) of 45%
The patient's LVEF of 45% falls into the category of heart failure with mildly reduced ejection fraction (HFmrEF), which is defined as an LVEF of 41-49% 4.
- The following medications can be considered for treatment:
- Additionally, sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to improve outcomes in HF across the full spectrum of LVEF, including HFmrEF 6.
- Other treatment options may include diuretics and salt restriction in individuals with fluid retention, as well as exercise training 7, 8.
- It is essential to note that the treatment of HFmrEF is not as well-established as that of heart failure with reduced ejection fraction (HFrEF), and the benefits of certain medications may extend to patients with HFmrEF, but this is an area of ongoing debate 6.