What are the next steps for an asymptomatic 67-year-old male with HTN (hypertension), LVEF (left ventricular ejection fraction) less than 40%, suspected LVH (left ventricular hypertrophy), and bradycardia?

Next Steps for Asymptomatic 67-Year-Old Male with LVEF <40%, Suspected LVH, Bradycardia, and HTN

Immediately initiate guideline-directed medical therapy (GDMT) with quadruple therapy for heart failure with reduced ejection fraction (HFrEF), while carefully monitoring heart rate and blood pressure given the bradycardia, and obtain confirmatory echocardiography to definitively assess LVEF and left ventricular structure. 1, 2

Immediate Diagnostic Workup

Confirm the diagnosis with transthoracic echocardiography to accurately measure LVEF, assess for true left ventricular hypertrophy (wall thickness, LV mass index), evaluate chamber dimensions, and assess for structural abnormalities including valvular disease. 1 This is the foundational diagnostic test that will guide all subsequent management decisions.

• Obtain baseline ECG to document the bradycardia, assess QRS duration and morphology (critical for future device therapy decisions), and evaluate for ECG criteria of LVH. 1, 3
• Measure natriuretic peptides (BNP or NT-proBNP) to confirm heart failure diagnosis and establish baseline values for monitoring. 1
• Assess renal function and electrolytes (serum creatinine, potassium) before initiating GDMT, as these are critical safety parameters. 1, 4
• Evaluate for ischemic etiology with consideration of stress testing or coronary angiography, as revascularization may improve outcomes in patients with multivessel coronary disease and LVEF ≤35%. 1, 2

Pharmacological Management

Initiate quadruple therapy for HFrEF despite the patient being asymptomatic, as these medications reduce mortality and prevent disease progression even in early stages. 1, 2

Core GDMT Components (Start Simultaneously When Possible):

• ACE inhibitor or ARB (or preferably ARNI if tolerated) to reduce total mortality and sudden cardiac death. 1, 2 Start at low doses and uptitrate to target or maximally tolerated doses.

• Beta-blocker with proven mortality benefit (carvedilol, metoprolol succinate, or bisoprolol) to reduce mortality by approximately 35%. 1, 2 However, exercise caution given the bradycardia - start at very low doses and monitor heart rate closely. Beta-blockers are still recommended for rate control even in patients with bradycardia, but titration must be gradual. 1, 2

• Mineralocorticoid receptor antagonist (spironolactone 25 mg daily or eplerenone) for patients with LVEF ≤35% to reduce mortality and hospitalization. 1, 4 Monitor potassium and renal function closely - avoid if baseline potassium >5.0 mEq/L or creatinine >2.5 mg/dL. 1, 4

• SGLT2 inhibitor (dapagliflozin or empagliflozin) to reduce cardiovascular events and mortality independent of diabetes status. 1, 2 This is now a cornerstone therapy with Class I recommendation.

Critical Considerations for Bradycardia:

The presence of bradycardia does NOT contraindicate beta-blocker therapy, but requires careful dose titration and monitoring. 1 If the patient develops symptomatic bradycardia or heart rate <50 bpm with symptoms, consider:

• Reducing beta-blocker dose rather than discontinuing
• Evaluating for other causes of bradycardia (medications, conduction disease)
• Assessing need for permanent pacemaker if symptomatic bradycardia persists despite medication adjustment 2

Blood Pressure Management

Treat the hypertension aggressively as this is a Class I recommendation to prevent or delay HF progression. 1 The GDMT medications (ACE inhibitor/ARB/ARNI) will simultaneously address both HFrEF and hypertension. Monitor blood pressure closely during uptitration to avoid hypotension.

Monitoring and Follow-up

• Frequent follow-up visits initially (every 1-2 weeks) during medication initiation and uptitration to monitor heart rate, blood pressure, renal function, and potassium. 1, 4
• Check serum potassium and creatinine every 4 weeks for the first 12 weeks, then every 3 months for the first year when on MRA therapy. 1, 4
• Repeat echocardiography in 3-6 months to assess response to therapy and potential improvement in LVEF. 1

Device Therapy Considerations

Evaluate for ICD candidacy once the patient has been on optimal GDMT for at least 3 months. 1, 2 If LVEF remains ≤35% despite GDMT:

• ICD is indicated for primary prevention if LVEF ≤35% with NYHA class II-III symptoms, or LVEF ≤30% with NYHA class I symptoms, and reasonable expectation of survival >1 year. 1, 2
• Assess for CRT candidacy if QRS duration ≥150 ms with LBBB morphology and LVEF ≤35%. 1, 2

Special Considerations for LVH

ECG LVH is an independent predictor of worse outcomes in heart failure patients and is associated with increased risk of developing atrial fibrillation. 3, 5 Aggressive blood pressure control and GDMT may lead to regression of LVH, which is associated with improved outcomes and reduced incidence of new-onset atrial fibrillation. 5

Common Pitfalls to Avoid

• Do not delay GDMT initiation because the patient is asymptomatic - early intervention prevents progression and reduces mortality. 1
• Do not withhold beta-blockers solely due to bradycardia unless the patient is symptomatic or has high-grade AV block. 1, 2
• Do not undertitrate medications - aim for target or maximally tolerated doses, as higher doses are associated with better outcomes. 6, 7
• Do not forget to check potassium and renal function regularly when using MRAs and ACE inhibitors/ARBs together. 1, 4
• Do not assume LVH is present based on clinical suspicion alone - confirm with echocardiography as ECG criteria have limited sensitivity. 3