What is the best treatment plan for a patient with heart failure, presenting with an S3 gallop, crackles, expiratory wheezes, lower extremity edema, cardiomegaly, pulmonary venous congestion, and a left ventricular ejection fraction (LVEF) of 40-45%?

Treatment Plan for Heart Failure with Reduced Ejection Fraction (LVEF 40-45%)

Immediate Management of Acute Decompensation

This patient presents with acute decompensated heart failure requiring immediate diuretic therapy to relieve pulmonary congestion and peripheral edema. 1

Diuretic Therapy

• Initiate intravenous loop diuretics immediately for patients presenting with signs of fluid overload (S3 gallop, crackles, wheezes, edema, pulmonary venous congestion on chest x-ray) 1
• If not previously on diuretics: start with furosemide 20-40 mg IV 1
• If already on chronic oral diuretics: initial IV dose should be at least equivalent to the oral dose 1
• Monitor symptoms, urine output, renal function, and electrolytes regularly during IV diuretic therapy 1, 2, 3
• Daily weights are essential to track fluid status 3

Fluid and Sodium Restriction

• Implement strict sodium restriction (<2g/day) given the presence of pulmonary congestion and peripheral edema 3
• Fluid restriction to 1.5-2 L/day is advised in this acute decompensated state 1, 3

Long-Term Pharmacological Management

Once stabilized, this patient requires guideline-directed medical therapy (GDMT) with neurohormonal antagonists, which have proven mortality benefit in heart failure with reduced ejection fraction. 1

First-Line Therapy (Class I Recommendations)

1. ACE Inhibitor (or ARB if ACE-I intolerant) 1

• ACE inhibitors are recommended as first-line therapy for LVEF <40-45% with or without symptoms 1
• Uptitrate to target doses proven effective in clinical trials, not based on symptomatic improvement alone 1
• Start at low dose and titrate upward (e.g., lisinopril 2.5-5 mg daily, target 32.5-35 mg daily) 4
• Monitor renal function and electrolytes before initiation, 1-2 weeks after each dose increment, and at 3-6 month intervals 1
• High doses of ACE inhibitors reduce hospitalizations for heart failure by 24% compared to low doses 4

2. Beta-Blocker 1

• One of three specific beta-blockers is recommended: bisoprolol, carvedilol, or metoprolol succinate 1
• Initiate once acute decompensation is stabilized and patient is euvolemic 1
• Start at low dose and uptitrate to target doses from clinical trials 1

3. Mineralocorticoid Receptor Antagonist (MRA) 1

• Recommended for patients who remain symptomatic despite ACE inhibitor and beta-blocker 1
• Spironolactone or eplerenone 1
• Monitor potassium and renal function closely 1

Second-Line Therapy for Persistent Symptoms

4. Sacubitril/Valsartan (ARNI) 1

• Recommended as replacement for ACE inhibitor in ambulatory patients who remain symptomatic despite optimal therapy with ACE-I, beta-blocker, and MRA 1
• Further reduces risk of heart failure hospitalization and death compared to ACE inhibitor alone 1
• Do not combine with ACE inhibitor due to angioedema risk 1

5. Ivabradine 1, 5

• Should be considered if heart rate remains ≥70 bpm despite maximally tolerated beta-blocker dose 1
• Requires sinus rhythm 5
• Start at 5 mg twice daily, titrate to 7.5 mg twice daily to maintain heart rate 50-60 bpm 5

Device Therapy Considerations

Implantable Cardioverter-Defibrillator (ICD)

• ICD is recommended for primary prevention if LVEF ≤35% persists after ≥3 months of optimal medical therapy, with expected survival >1 year with good functional status 1
• This patient's LVEF of 40-45% currently does not meet criteria, but reassess after 3 months of optimal medical therapy 1
• If ischemic etiology: Class I, Level A recommendation 1
• If non-ischemic etiology: Class I, Level B recommendation 1

Cardiac Resynchronization Therapy (CRT)

• Evaluate ECG for QRS duration and morphology 1
• CRT is recommended if: 1
  • QRS duration ≥150 msec with LBBB morphology and LVEF ≤35% (Class I, Level A)
  • QRS duration 130-149 msec with LBBB morphology and LVEF ≤35% (Class I, Level B)
• CRT is contraindicated if QRS duration <130 msec 1

Medications to Avoid

The following medications worsen heart failure and must be avoided: 1

• NSAIDs and COX-2 inhibitors - increase risk of heart failure worsening and hospitalization 1, 3
• Diltiazem or verapamil - increase risk of heart failure worsening and hospitalization 1
• Thiazolidinediones (glitazones) - increase risk of heart failure worsening and hospitalization 1
• Class I antiarrhythmic agents 1
• Short-acting dihydropyridine calcium antagonists 1
• Tricyclic antidepressants 1

Do not add an ARB to the combination of ACE-I and MRA due to increased risk of renal dysfunction and hyperkalemia 1

Non-Pharmacological Management

Exercise and Activity

• Physical rest is recommended during acute decompensation 1
• Once stabilized, encourage exercise training programs to improve skeletal muscle function and functional capacity 1
• Exercise training is encouraged in stable NYHA class II-III patients 1

Alcohol

• Moderate alcohol intake (one beer, 1-2 glasses of wine/day) is permitted unless alcoholic cardiomyopathy, in which case it is prohibited 1

Common Pitfalls to Avoid

• Inadequate diuresis leading to persistent congestion and hospital readmissions 3
• Overdiuresis causing hypotension, renal dysfunction, and electrolyte abnormalities 3
• Maintaining patients on very low doses of ACE inhibitors when higher doses can be tolerated - high doses reduce hospitalizations significantly 4
• Using NSAIDs or COX-2 inhibitors which worsen heart failure 1, 3
• Failing to uptitrate GDMT to target doses from clinical trials 1
• Neglecting to monitor renal function and electrolytes during medication titration 1, 2

Monitoring Strategy

• Regular assessment of symptoms, weight, blood pressure, heart rate 3
• Renal function and electrolytes: before treatment, 1-2 weeks after each dose change, at 3-6 month intervals, and during any hospitalization 1
• Reassess LVEF after 3 months of optimal medical therapy to determine ICD eligibility 1
• More frequent monitoring in patients with renal dysfunction or electrolyte disturbances 1