Treatment of Impaired Left Ventricular Systolic Function
The cornerstone treatment for impaired left ventricular systolic function includes ACE inhibitors, beta-blockers, diuretics, and in appropriate cases, aldosterone antagonists, with newer agents like sacubitril/valsartan now recommended for patients with chronic heart failure and reduced ejection fraction. 1, 2
First-Line Pharmacologic Therapy
- ACE inhibitors should be prescribed for all patients with symptomatic heart failure and those with asymptomatic left ventricular dysfunction, unless contraindicated or not tolerated 1
- Beta-blockers (specifically bisoprolol, carvedilol, and metoprolol XL/CR) should be used in conjunction with ACE inhibitors 1, 3
- Diuretics should be used to control fluid retention and sodium balance, even when patients are rendered free of edema 1
- Sacubitril/valsartan (ARNI) is indicated to reduce the risk of cardiovascular death and hospitalization in patients with chronic heart failure with reduced ejection fraction 2, 4
Second-Line and Alternative Therapies
- Angiotensin receptor blockers (ARBs) should be used in patients who cannot tolerate ACE inhibitors due to cough or angioedema 1, 3
- A combination of hydralazine and nitrates is recommended for patients who cannot tolerate ACE inhibitors due to hypotension or renal insufficiency 1
- Spironolactone is recommended for patients with recent or current NYHA class IV symptoms who have preserved renal function and normal potassium levels 1
- Digoxin at low doses (serum concentration <1 ng/mL) can be added to improve symptoms 3
Therapies Based on Specific Conditions
- For patients with atrial fibrillation, drugs suppressing AV conduction should be used to control ventricular rate 1
- Anticoagulation is indicated in patients with atrial fibrillation or previous systemic/pulmonary embolization 1, 3
- Exercise training is recommended as an adjunctive approach to improve clinical status in ambulatory patients 1
Therapies Not Recommended (Class III)
- Long-term intermittent use of positive inotropic drugs 1
- Calcium channel blocking drugs as treatment for heart failure with reduced ejection fraction 1
- Routine use of nutritional supplements (coenzyme Q10, carnitine, taurine, antioxidants) or hormonal therapies 1
- Use of ARBs instead of ACE inhibitors in patients who can tolerate ACE inhibitors 1
- Use of ARBs before beta-blockers in patients taking an ACE inhibitor 1
Management of Advanced Heart Failure (Stage D)
- For patients with refractory end-stage heart failure, specialized treatment strategies should be considered, including 1:
- Mechanical circulatory support
- Continuous intravenous positive inotropic therapy
- Referral for cardiac transplantation
- Hospice care
Special Considerations
- In patients with severe renal impairment, medication doses should be reduced and monitored carefully 1, 5
- Neurohormonal antagonism may be less well tolerated in patients with severe symptoms than those with mild symptoms 1, 3
- Meticulous control of fluid retention is critical in the management of advanced heart failure 1
Common Pitfalls to Avoid
- Failure to distinguish between systolic and diastolic dysfunction before initiating therapy 6
- Underuse of ACE inhibitors and beta-blockers in patients with end-stage renal disease due to concerns about adverse reactions 5
- Using calcium channel blockers (except amlodipine) in patients with reduced systolic function 3, 6
- Delaying treatment in asymptomatic patients with left ventricular dysfunction, which can lead to disease progression 7
By following this evidence-based approach to treating impaired left ventricular systolic function, clinicians can improve survival, decrease hospitalizations, and reduce symptoms in patients with heart failure.