How should a provider manage a patient with dilated cardiomyopathy?

From the Guidelines

Management of a patient with dilated cardiomyopathy should focus on optimal medical therapy, including ACE inhibitors, beta-blockers, and MRA, to reduce the risk of sudden death and progressive heart failure, as recommended by the European Society of Cardiology (ESC) guidelines 1. The approach to managing dilated cardiomyopathy involves a comprehensive strategy that includes pharmacological interventions, lifestyle modifications, and device therapy when necessary.

• First-line medications should include ACE inhibitors (like enalapril 2.5-20 mg twice daily or lisinopril 5-40 mg daily) or ARBs if ACE inhibitors are not tolerated, along with beta-blockers (such as carvedilol 3.125-25 mg twice daily or metoprolol succinate 12.5-200 mg daily) to reduce morbidity and mortality.
• Diuretics like furosemide 20-80 mg daily should be added for fluid overload symptoms, and for patients with ejection fraction ≤35%, an aldosterone antagonist (spironolactone 25-50 mg daily) should be considered.
• SGLT2 inhibitors like dapagliflozin 10 mg daily have shown benefit regardless of diabetes status, as noted in recent clinical practice guidelines 1.
• Lifestyle modifications are essential, including sodium restriction (<2-3 g/day), fluid restriction if needed, regular moderate exercise, smoking cessation, and limited alcohol intake.
• For patients with persistent symptoms despite optimal medical therapy, consider device therapy such as an implantable cardioverter-defibrillator for primary prevention of sudden cardiac death or cardiac resynchronization therapy for those with wide QRS complex, as these interventions can significantly improve quality of life and reduce mortality. The goal of these interventions is to reduce cardiac workload, prevent adverse remodeling, improve contractility, and optimize hemodynamics, ultimately improving symptoms, quality of life, and survival in patients with dilated cardiomyopathy, in line with the recommendations from the American Heart Association 1.

From the Research

Management of Dilated Cardiomyopathy

The management of dilated cardiomyopathy (DCM) involves a combination of pharmacological and non-pharmacological therapies.

• The use of beta-blockers is recommended as they have been shown to improve mortality and morbidity in patients with DCM 2, 3, 4.
• Angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are also recommended as they have been shown to improve left ventricular function and reduce cardiovascular events 5, 4.
• The use of diuretics, aldosterone antagonists, and ivabradine may also be beneficial in certain patients 4.
• Devices such as automatic implantable cardioverter defibrillators and cardiac resynchronisation therapy may be considered in patients with advanced disease 4.

Pharmacological Therapy

The choice of pharmacological therapy depends on the individual patient's needs and circumstances.

• Beta-blockers such as metoprolol, carvedilol, and bisoprolol have been shown to be effective in reducing mortality and morbidity in patients with DCM 2, 3.
• ACE inhibitors or ARBs such as benazepril or valsartan may be used to improve left ventricular function and reduce cardiovascular events 5.
• The use of supramaximal doses of ACE inhibitors or ARBs may be beneficial in certain patients, but further research is needed to confirm this 5.

Clinical Practice Guidelines

Clinical practice guidelines recommend a multidisciplinary approach to the management of DCM, including the use of multimodality cardiovascular imaging and genetic counselling 6.

• The formation of multidisciplinary management teams and the role of cascade genetic testing are areas of variation between guidelines 6.
• Further research is needed to address evidence gaps and inform future guideline development 6.