From the Guidelines
Treatment of congestive heart failure (CHF) in patients with severely reduced left ventricular ejection fraction (LVEF) of 20% should prioritize guideline-directed medical therapy, including the use of diuretics, ACE-I or ARNI, beta-blockers, and mineralocorticoid receptor antagonists, as recommended by the 2016 ESC guidelines 1.
Key Components of Treatment
- Diuretics, such as furosemide, are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1.
- Sacubitril/valsartan is recommended as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.
- Beta-blockers, such as carvedilol, metoprolol succinate, or bisoprolol, should be used to reduce sympathetic activation and improve cardiac efficiency.
- Mineralocorticoid receptor antagonists, like spironolactone, can be added in selected patients with moderately severe to severe symptoms of HF and reduced LVEF, as recommended by the 2005 ACC/AHA guidelines 1.
Device Therapy
- For patients who remain symptomatic despite optimal medical therapy, device therapy should be considered, including an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death and cardiac resynchronization therapy (CRT) if there is a wide QRS complex, as recommended by the 2005 ACC/AHA guidelines 1.
Uptitration and Monitoring
- Medications should be initiated at low doses and gradually uptitrated to target doses as tolerated, with close monitoring of renal function, potassium levels, and signs of congestion.
- Regular follow-up and adjustment of treatment as needed are crucial to optimize outcomes and improve quality of life in patients with severely reduced ejection fraction.
From the FDA Drug Label
1 Adult Heart Failure Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction.
2 Adult Heart Failure The recommended starting dose of sacubitril and valsartan tablet is 49/51 mg orally twice-daily. Double the dose of sacubitril and valsartan tablets after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily, as tolerated by the patient.
Treatment of CHF in patients with LVEF of 20% can be managed with sacubitril and valsartan tablets, as they are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction. The recommended starting dose is 49/51 mg orally twice-daily, and the dose can be doubled after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily, as tolerated by the patient 2.
Alternatively, ivabradine can be considered for patients with CHF and LVEF ≤ 35%, as demonstrated in the SHIFT trial, which showed a reduction in the risk of hospitalization for worsening heart failure or cardiovascular death 3.
- Key points:
- Sacubitril and valsartan tablets can be used to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with CHF and reduced ejection fraction.
- Ivabradine can be considered for patients with CHF and LVEF ≤ 35%.
- The recommended dose of sacubitril and valsartan tablets is 49/51 mg orally twice-daily, which can be doubled after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily.
From the Research
Treatment of CHF in Patients with LVEF of 20%
- The treatment of chronic heart failure (CHF) in patients with left ventricular ejection fraction (LVEF) of 20% is a complex issue, and the available evidence suggests that a combination of medications can be effective in improving outcomes 4, 5.
- Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system (RAAS) are commonly used in the treatment of CHF, and studies have shown that they can improve survival and reduce morbidity in patients with reduced LVEF 4.
- A study published in the European Journal of Heart Failure found that combined treatment with ACEi/ARB and β-blockers was associated with improved outcomes, including reduced all-cause mortality and hospitalization for HF 5.
- The same study found that up-titrating β-blockers to target dose was associated with a greater reduction in hazards of all-cause mortality than up-titrating ACEi/ARB 5.
- Another study published in The Cochrane Database of Systematic Reviews found that mineralocorticoid receptor antagonists (MRAs) probably reduce heart failure hospitalization, but have little or no effect on cardiovascular mortality and quality of life 4.
- The use of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and angiotensin receptor neprilysin inhibitors (ARNIs) in patients with CHF and reduced LVEF is also supported by the available evidence, although the treatment effect sizes are modest 4.
Medication Options
- Beta-blockers: may reduce the risk of cardiovascular mortality, but further trials are needed to confirm this effect 4.
- ACEIs: likely have little or no effect on cardiovascular mortality, all-cause mortality, and heart failure hospitalization 4.
- ARBs: have little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalization, and quality of life 4.
- MRAs: probably reduce heart failure hospitalization, but have little or no effect on cardiovascular mortality and quality of life 4.
- ARNIs: may have little or no effect on cardiovascular mortality, all-cause mortality, and quality of life, but may result in a slight reduction in heart failure hospitalization 4.