What treatment is needed for a patient with a low ejection fraction (EF) of less than 30?

Management of Patients with Ejection Fraction Less Than 30%

Patients with EF <30% require comprehensive guideline-directed medical therapy (GDMT) including ACE inhibitors or ARNIs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, along with ICD therapy for primary prevention of sudden cardiac death in most cases. 1

Pharmacologic Therapy

Foundational Medications (Start Simultaneously or in Rapid Sequence)

• ACE inhibitors or ARBs should be initiated immediately in all patients with EF ≤30%, as they reduce mortality and delay heart failure progression 1

  • ARNIs (sacubitril/valsartan) are preferred over ACE inhibitors when tolerated, providing superior reduction in cardiovascular death and hospitalization 2
  • Start at low doses and titrate every 2-4 weeks to target maintenance doses 1

• Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) must be started in all patients with EF ≤30% unless contraindicated 1

  • Initiate at low doses after patient stabilization and gradually titrate to target doses 3
  • These agents reduce mortality and prevent disease progression even in asymptomatic patients 1

• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) should be added to the regimen 3

  • Start as soon as possible as they have minimal blood pressure effects while providing significant mortality benefit 3
  • Monitor potassium and renal function closely 1

• SGLT2 inhibitors should be initiated early in treatment 3, 4

  • These agents provide mortality benefit with minimal blood pressure-lowering effects 3
  • Can be started simultaneously with other GDMT medications 4

Implementation Strategy

• Start multiple medications simultaneously rather than waiting to reach target doses of one medication before starting another 3, 5
• For patients with low blood pressure, begin with SGLT2 inhibitors and MRAs first (minimal BP effect), followed by beta-blockers or ACE inhibitors/ARNIs at low doses 3
• Titrate gradually to target doses over 6-12 weeks with close monitoring of symptoms, blood pressure, renal function, and electrolytes 3

Device Therapy

ICD Implantation (Primary Prevention)

• ICD therapy is Class I recommendation for patients with EF ≤30% who are at least 40 days post-MI, NYHA class I symptoms, on GDMT, and expected to survive >1 year 1
• ICD therapy is also Class I for patients with EF ≤35%, at least 40 days post-MI, NYHA class II-III symptoms, on GDMT, and expected survival >1 year 1
• Counseling must include discussion of sudden death risk, device efficacy, complications, and option for deactivation at end of life 1

Cardiac Resynchronization Therapy (CRT)

• CRT is indicated for patients with EF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, and NYHA class II-IV symptoms on GDMT 1
• CRT can be useful for patients with EF ≤35% undergoing device implantation with anticipated ventricular pacing >40% 1

Monitoring Parameters

• Renal function and electrolytes should be checked 1-2 weeks after each dose increment, at 3 months, then every 6 months 3
• Regular assessment of symptoms, functional capacity, blood pressure, heart rate, and rhythm is essential 3
• Monitor for signs of volume overload requiring diuretic adjustment 1

Additional Considerations

Diuretics

• Loop diuretics should be used to manage volume overload and reduce ventricular filling pressure 1
• Adjust doses based on daily weights and clinical signs of congestion 1

Medications to Avoid

• NSAIDs should be avoided as they worsen renal function and counteract beneficial effects of heart failure medications 3
• Negative inotropic calcium channel blockers (verapamil, diltiazem) are not recommended in patients with EF <40% 1
• Reassess and consider discontinuing negative inotropic agents (verapamil, diltiazem, disopyramide) if systolic dysfunction develops 1

Advanced Therapies

Heart Transplantation

• Consider heart transplantation for patients with advanced (end-stage) heart failure, EF <50%, not amenable to other interventions, and on maximal medical therapy 1
• Transplantation should not be performed in mildly symptomatic patients 1

Common Pitfalls to Avoid

• Underutilization of GDMT and inadequate dose titration remain the most common issues in heart failure management 3, 5
• Delaying initiation of multiple medications sequentially rather than starting them simultaneously or in rapid sequence 5, 4
• Failing to uptitrate medications to target doses due to excessive caution about side effects 5
• Not reassessing ICD candidacy in patients with high risk of non-sudden death (frequent hospitalizations, frailty, severe comorbidities) 1