From the Guidelines
For a patient with an LVEF of 50%, indicating mildly impaired systolic function, the most appropriate medication recommendations include diuretics, SGLT2 inhibitors, ACE inhibitors or ARBs, and beta-blockers, as these have shown benefit in reducing hospitalizations and improving symptoms in patients with heart failure with preserved ejection fraction (HFpEF) 1.
Medication Recommendations
- Diuretics like furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily) are used to manage fluid overload and symptoms.
- SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) have shown benefit in reducing hospitalizations.
- Blood pressure control is essential, typically with ACE inhibitors like lisinopril (10-40mg daily) or ARBs such as losartan (25-100mg daily).
- Beta-blockers like metoprolol succinate (25-200mg daily) may help with rate control if the patient has atrial fibrillation.
- Spironolactone (25mg daily) can be considered in selected patients with HFpEF.
Rationale
These medications work through various mechanisms including reducing fluid retention, decreasing cardiac workload, and modifying neurohormonal activation that contributes to heart failure progression 1.
Considerations
Treatment should be individualized based on comorbidities such as hypertension, diabetes, and kidney function, with careful monitoring for side effects and electrolyte abnormalities 1.
Guideline Recommendations
The 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends the use of these medications in patients with HFpEF, with a focus on individualized treatment and careful monitoring 1.
Clinical Implications
The use of these medications in patients with an LVEF of 50% can help improve symptoms, reduce hospitalizations, and improve quality of life, while also reducing morbidity and mortality 1.
From the FDA Drug Label
Asymptomatic Left Ventricular Dysfunction In clinically stable asymptomatic patients with left ventricular dysfunction (ejection fraction ≤35 percent), enalapril maleate decreases the rate of development of overt heart failure and decreases the incidence of hospitalization for heart failure The medication enalapril is considered for patients with left ventricular dysfunction, but the specified ejection fraction in the label is ≤35 percent, which does not directly match the 50% LVEF in the question.
- The label does not provide information for an LVEF of 50%.
- Enalapril may be considered for patients with symptomatic congestive heart failure, usually in combination with diuretics and digitalis, but the LVEF value is not specified for this condition. Since the provided LVEF of 50% is not directly addressed in the label, no conclusion can be drawn for this specific value 2
From the Research
Medications for Left Ventricular Ejection Fraction (LVEF) of 50%
For a patient with an LVEF of 50%, indicating mildly impaired systolic function, the following medications are considered:
- Diuretics to reduce ventricular filling pressure 3
- Calcium channel blockers (CCBs) and antagonists of the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aldosterone antagonists to treat hypertension 3
- Antiplatelet therapy, anticoagulants, and β-blockers to treat ischemic heart disease 3
- β-blockers and digoxin for heart rate control in atrial fibrillation 3
- ACE inhibitors and ARBs to potentially decrease LV hypertrophy in hypertensive patients with HFNEF 3
Treatment Approach
The treatment approach for patients with an LVEF of 50% is similar to those with reduced LVEF, with a focus on:
- Reducing LV filling pressure
- Controlling hypertension
- Modifying ischemia
- Improving LV relaxation 3
- Using a combination of medications, including beta-blockers, ACE inhibitors, and diuretics 4
Specific Medications
Some specific medications that may be considered for patients with an LVEF of 50% include: