What is the management plan for a patient with a left ventricular ejection fraction (LVEF) of 25-35%?

Management Plan for Patients with Left Ventricular Ejection Fraction of 25-35%

For patients with left ventricular ejection fraction (LVEF) of 25-35%, a comprehensive guideline-directed medical therapy (GDMT) approach is recommended, including pharmacological therapy, device therapy consideration, and revascularization evaluation when appropriate.

Pharmacological Therapy

First-Line Medications

• ACE inhibitors (or ARBs if intolerant) are recommended for all patients with LVEF ≤35-40% to reduce total mortality and sudden cardiac death 1, 2
• Beta-blockers are recommended for all patients with LVEF ≤35-40% to reduce mortality by approximately 35% and specifically reduce the incidence of sudden death 1
• Mineralocorticoid receptor antagonists (MRAs) such as spironolactone are recommended for patients already receiving ACE inhibitors and beta-blockers to reduce mortality and sudden death 1, 3
• SGLT2 inhibitors with proven cardiovascular benefit are recommended to reduce cardiovascular events, independent of diabetes status 1, 4

Additional Pharmacological Considerations

• The combination of hydralazine and nitrates is recommended for self-described African-American patients with moderate-severe symptoms despite optimal therapy with ACE inhibitors, beta-blockers, and diuretics 1
• GLP-1 receptor agonists with proven cardiovascular benefit should be considered, particularly semaglutide in patients with overweight or obesity (BMI >27 kg/m²) 1
• Low-dose colchicine (0.5 mg daily) should be considered to reduce myocardial infarction, stroke, and need for revascularization in patients with atherosclerotic coronary artery disease 1

Device Therapy

ICD Therapy

• An implantable cardioverter-defibrillator (ICD) is recommended for primary prevention of sudden cardiac death in patients with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT who have reasonable expectation of meaningful survival for >1 year 1
• ICD therapy is also recommended for patients with LVEF ≤30% and NYHA class I symptoms while receiving GDMT who have reasonable expectation of meaningful survival for >1 year 1

Cardiac Resynchronization Therapy (CRT)

• For patients with LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and quality of life 1
• CRT can be useful for patients with LVEF ≤35%, sinus rhythm, LBBB with QRS duration of 120-149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT 1
• CRT may be considered in patients with non-LBBB pattern with QRS duration of 120-149 ms and NYHA class III or ambulatory class IV symptoms 1
• CRT response rate is similar across different baseline LVEF subgroups, including those with very low LVEF (5-15%), showing no lower limit for baseline LVEF to predict non-response to CRT in eligible patients 5

Revascularization Considerations

• In patients with LVEF ≤35%, it is recommended to choose between revascularization or medical therapy alone after careful evaluation by a Heart Team of coronary anatomy, correlation between coronary artery disease and LV dysfunction, comorbidities, life expectancy, individual risk-to-benefit ratio, and patient perspectives 1
• In surgically eligible patients with multivessel coronary artery disease and LVEF ≤35%, myocardial revascularization with CABG is recommended over medical therapy alone to improve long-term survival 1
• Intracoronary pressure measurement (FFR or iFR) or computation (QFR) is recommended to guide lesion selection for intervention in patients with multivessel disease 1
• Intracoronary imaging guidance by IVUS or OCT is recommended when performing PCI on anatomically complex lesions 1

Management of Atrial Fibrillation in Patients with Reduced LVEF

• Beta-blockers are recommended as first-line agents for rate control in patients with atrial fibrillation and reduced ejection fraction (LVEF <40%) 6
• Amiodarone is an alternative option for patients with hemodynamic instability or severely reduced LVEF who cannot tolerate beta-blockers 6
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in patients with reduced left ventricular function (LVEF ≤40%) due to their negative inotropic effects 6

Monitoring and Follow-up

• Regular reassessment of LVEF is recommended to guide therapy adjustments, as HF is a dynamic disease that may worsen or improve over time 4, 7
• Patients should be monitored for potential adverse effects of medications, such as hyperkalemia or renal dysfunction with MRAs and ACE inhibitors 3, 2
• For patients with atrial fibrillation, initial resting heart rate target should be <110 bpm, and echocardiogram should be performed to determine further management and choice of maintenance therapy 6

Common Pitfalls to Avoid

• Using non-dihydropyridine calcium channel blockers in patients with LVEF <40%, which may worsen heart failure 6
• Discontinuing heart failure medications inappropriately, which increases risk of relapse of HF and LV dysfunction 4
• Failing to consider the need for anticoagulation based on stroke risk factors in patients with atrial fibrillation 6
• Overlooking the potential for LVEF improvement with appropriate therapy, as LVEF is subject to changes after intervention 8, 7