What treatment is recommended for a patient with a low ejection fraction and blood clots?

Treatment for Patient with EF 14% and Intracardiac Thrombi

This patient requires immediate systemic anticoagulation for at least 3 months, combined with aggressive guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), including beta-blockers, ARNI (sacubitril/valsartan), mineralocorticoid receptor antagonist, and SGLT2 inhibitor. 1, 2, 3

Immediate Anticoagulation Management

For Documented Thrombus

• Initiate systemic anticoagulation immediately for a minimum of 3 months given the presence of evident thrombus 1
• Warfarin targeting INR 2.0-3.0 (goal 2.5) is the standard approach, with or without aspirin 1
• Low molecular weight heparin (LMWH) is reasonable for patients unable to tolerate oral therapy 1
• Consider thrombolytic therapy or surgical thrombectomy if the thrombus causes hemodynamic obstruction, interferes with valve function, or is poorly adherent/mobile with high embolization risk 1

Ongoing Anticoagulation Beyond 3 Months

• With an EF of 14% (well below the 25% threshold), ongoing systemic anticoagulation is reasonable even after the initial 3-month treatment period 1
• This recommendation is based on the extremely low ejection fraction (<25%), which represents a Class IIa indication for continued anticoagulation 1
• While evidence in sinus rhythm HFrEF patients shows no overall mortality benefit from warfarin, patients with EF <20% likely have a favorable risk-benefit ratio for anticoagulation 1, 4, 5

Comprehensive HFrEF Medical Therapy

First-Line Quadruple Therapy (Start Simultaneously)

The following four medication classes should be initiated together at low doses and uptitrated, rather than sequentially:

1. Beta-Blocker 1, 3

• Evidence-based options: carvedilol, metoprolol succinate, or bisoprolol
• Start at low dose and titrate to target over 6-12 weeks
• Reduces mortality and HF hospitalization

2. ARNI (Sacubitril/Valsartan) 1, 2, 3

• Preferred over ACE inhibitors/ARBs as it provides superior reduction in HF hospitalization and death 2, 3
• Starting dose: 24/26 mg twice daily (given severe HFrEF and likely borderline blood pressure) 2
• Target dose: 97/103 mg twice daily, uptitrating every 2-4 weeks as tolerated 2
• If transitioning from ACE inhibitor, require 36-hour washout period to avoid angioedema 2
• No washout needed if switching from ARB 2

3. Mineralocorticoid Receptor Antagonist (MRA) 1, 3

• Spironolactone or eplerenone
• Monitor potassium and renal function closely, especially with concurrent anticoagulation 6

4. SGLT2 Inhibitor 1, 6, 3

• Dapagliflozin or empagliflozin should be started immediately, even during hospitalization if applicable 6, 3
• Benefits accrue rapidly within days to weeks 6
• Minimal blood pressure effects and no excess kidney risk 6
• Deferring to outpatient setting results in >75% chance of never starting within the next year 6

Diuretic Therapy for Congestion

• Loop diuretics as needed for volume management 1, 6, 3
• May need to reduce diuretic doses when initiating sacubitril/valsartan due to enhanced natriuresis 2
• Monitor daily weights, fluid status, and electrolytes 6

Critical Monitoring Parameters

During Anticoagulation

• INR monitoring if using warfarin (target 2.0-3.0) 1
• Assess for bleeding complications 1
• Serial echocardiography to evaluate thrombus resolution 1

During GDMT Initiation and Uptitration

• Blood pressure monitoring (especially with sacubitril/valsartan) - symptomatic hypotension can usually be managed through patient education without reducing therapy 2, 6
• Renal function and electrolytes (particularly potassium with MRA and anticoagulation) 2, 6, 3
• Heart rate monitoring with beta-blocker titration 3
• Daily weights and volume status 6

Common Pitfalls to Avoid

• Do not delay GDMT initiation - start immediately as delayed initiation is associated with never initiating GDMT 1
• Do not stop beta-blockers or ARNI during hospitalization unless true hemodynamic instability (hypotension with hypoperfusion) exists 6
• Do not accept asymptomatic hypotension as a reason to avoid target doses - 40% of patients requiring temporary dose reduction can be restored to target doses 2
• Do not start medications sequentially - initiate multiple GDMT medications simultaneously at low doses, then uptitrate together 1, 3
• Do not discontinue anticoagulation at 3 months without reassessing - with EF 14%, ongoing anticoagulation is reasonable 1
• Avoid NSAIDs as they worsen renal function and counteract GDMT benefits 3

Device Therapy Consideration

• Once on optimal medical therapy for ≥3 months, reassess for ICD candidacy if EF remains ≤35% and patient has NYHA Class II-III symptoms 3
• Consider cardiac resynchronization therapy (CRT) if QRS ≥150 msec with LBBB morphology 3