What is the management of a patient with new onset congestive heart failure (CHF) and a reduced ejection fraction (EF) of 30%?

Management of New Onset Heart Failure with Reduced Ejection Fraction (EF 30%)

Immediately initiate quadruple guideline-directed medical therapy (GDMT) with an ACE inhibitor (or ARB/ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor, while simultaneously addressing volume status with diuretics—this comprehensive approach should begin during hospitalization once clinical stability is achieved. 1

Initial Assessment and Stabilization

Volume Status Management

• Assess for congestion by examining jugular venous distention, peripheral edema, pulmonary rales, and orthopnea 1
• Initiate loop diuretics to relieve congestion and reduce extracardiac fluid volume excess 1
• For patients previously on oral diuretics, start intravenous loop diuretics at 2.5 times the total daily oral dose to achieve adequate diuresis 1
• Monitor daily weights, fluid intake/output, and serial electrolytes (potassium, creatinine, BUN) during active diuresis 1
• Intensify diuretic regimen if inadequate response by: (a) increasing loop diuretic dose, (b) adding a second diuretic like metolazone or IV chlorothiazide, or (c) using continuous infusion of loop diuretics 1

Hemodynamic Assessment

• Invasive hemodynamic monitoring should be performed if respiratory distress or impaired perfusion is present and adequacy of filling pressures cannot be determined clinically 1
• Target a renal perfusion pressure (mean arterial pressure minus central venous pressure) ideally >60 mm Hg 1

Initiation of Guideline-Directed Medical Therapy

ACE Inhibitor or ARB Therapy

• Start an ACE inhibitor during hospitalization after achieving clinical stability and adequate diuresis 1
• Lisinopril: start 2.5-5 mg daily, target 20-35 mg daily 1
• Enalapril: start 2.5 mg twice daily, target 10-20 mg twice daily 1
• Continue ACE inhibitor even with mild renal function decline or asymptomatic blood pressure reduction during hospitalization 1

Beta-Blocker Therapy

• Initiate beta-blocker therapy after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropes 1
• Start at low doses only in stable patients: carvedilol 3.125 mg twice daily (target 25-50 mg twice daily), bisoprolol 1.25 mg daily (target 10 mg daily), or metoprolol succinate 12.5-25 mg daily (target 200 mg daily) 1
• Use particular caution when initiating beta-blockers in patients who required inotropes during hospitalization 1

Mineralocorticoid Receptor Antagonist

• Add spironolactone 25 mg daily (target 25-50 mg daily) or eplerenone 25 mg daily (target 50 mg daily) 1, 2
• MRAs are indicated for NYHA Class III-IV heart failure with reduced EF to increase survival, manage edema, and reduce hospitalization 2
• Monitor potassium and creatinine closely given risk of hyperkalemia, particularly when combined with ACE inhibitors 1

SGLT2 Inhibitor

• Initiate SGLT2 inhibitor therapy as part of foundational GDMT, as these agents provide mortality and hospitalization benefits in HFrEF 1

Diagnostic Workup

Essential Testing

• Echocardiogram to confirm EF, assess diastolic function, chamber size, wall thickness, and valvular abnormalities 1
• BNP or NT-proBNP to confirm diagnosis and establish baseline 1
• Complete metabolic panel, liver function tests, complete blood count, iron studies, thyroid studies, HbA1c 1
• Electrocardiogram to assess for ischemia, arrhythmias, and QRS duration (for future CRT consideration) 1
• Chest X-ray to evaluate pulmonary congestion and cardiomegaly 1
• Consider coronary angiography to evaluate for ischemic etiology, particularly if new-onset HF without clear cause 1

Medication Titration Strategy

Serial Evaluation Protocol

• Schedule follow-up visits every 1-2 weeks during medication titration phase 1
• At each visit: assess volume status, vital signs, symptoms, and obtain basic metabolic panel as indicated 1
• If volume overload persists: adjust diuretics first, then follow up in 1-2 weeks 1
• If euvolemic and stable: start, increase, or switch GDMT medications, then follow up in 1-2 weeks 1
• Continue this cycle until target doses are achieved or maximum tolerated doses are reached 1

Target Doses

• Aim for evidence-based target doses from clinical trials rather than arbitrary "tolerated" doses 1
• Do not routinely discontinue GDMT for mild renal function decline or asymptomatic hypotension 1

Transition to Outpatient Care

Discharge Planning

• Transition from IV to oral diuretics with careful attention to dosing and electrolyte monitoring 1
• Provide comprehensive written discharge instructions emphasizing: diet (sodium restriction), discharge medications with focus on adherence and uptitration, activity level, follow-up appointments, daily weight monitoring, and what to do if symptoms worsen 1
• Ensure all GDMT is prescribed at discharge unless specific contraindications exist 1

Post-Discharge Follow-Up

• Arrange early follow-up within 7-14 days of discharge 1
• Utilize post-discharge systems of care when available to facilitate transition to effective outpatient management 1
• Repeat echocardiogram after 3-6 months of optimal GDMT to reassess EF and determine need for ICD or CRT 1

Referral Considerations

Indications for Heart Failure Specialist Referral

• All patients with new-onset HF should be referred for evaluation of etiology and assistance with GDMT optimization 1
• Persistently reduced EF ≤35% after ≥3 months of GDMT warrants referral for device therapy consideration (ICD, CRT) 1
• Use the I-NEED-HELP mnemonic for ongoing assessment: IV inotropes, NYHA IIIB/IV, Ejection fraction ≤35%, Defibrillator shocks, Hospitalizations >1, Edema despite escalating diuretics, Low blood pressure/high heart rate, Prognostic medication intolerance 1

Common Pitfalls to Avoid

• Do not delay GDMT initiation until after discharge—hospitalization is a critical opportunity to start these life-saving medications 1
• Do not discontinue GDMT for mild asymptomatic hypotension or small creatinine elevations (unless severe)—these medications improve survival even with these changes 1
• Do not use arbitrary low doses of GDMT—titrate to target doses from clinical trials 1
• Do not discharge patients with residual congestion without a clear plan for further diuresis, as this predicts higher readmission and mortality 1
• Do not forget to address precipitating factors such as medication non-adherence, dietary indiscretion, uncontrolled hypertension, or ischemia 1