Treatment of Ischemic Cardiomyopathy
All patients with ischemic cardiomyopathy should receive optimal medical therapy consisting of ACE inhibitors (or ARBs if intolerant), beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol), and statins, with consideration for coronary revascularization in those with demonstrable viable myocardium and suitable anatomy. 1, 2
Pharmacological Management
First-Line Medications (Mandatory)
ACE Inhibitors or ARBs:
- ACE inhibitors should be prescribed in all patients with ischemic cardiomyopathy who have LV ejection fraction ≤40%, regardless of symptoms 1
- Start with low doses and titrate upward: lisinopril 2.5-5 mg daily initially, target 20-40 mg daily 3
- ARBs (such as valsartan) are equally effective alternatives for patients intolerant of ACE inhibitors 1
- Do not combine ACE inhibitors and ARBs - this increases adverse events without improving survival 1
- Monitor renal function and potassium 1-2 weeks after initiation and after each dose increase 4
Beta-Blockers:
- Must use one of three proven agents: carvedilol, metoprolol succinate, or bisoprolol - these specifically reduce risk of death 1, 2
- Should be started even in asymptomatic patients with reduced LVEF 2
- Continue for at least 3 years in all patients with normal LV function after MI 1
- Titrate to target doses as tolerated; inadequate beta blockade is a common pitfall 2
Antiplatelet Therapy:
- Aspirin should be used in all patients unless contraindicated 1
- The combination provides additive benefits when ACE inhibitors and aspirin are used together 1
Statin Therapy:
- Lipid-lowering with statins is essential as part of optimal medical therapy 5
- Particularly important given the ischemic etiology 1
Additional Medications Based on Clinical Status
Aldosterone Antagonists:
- Add spironolactone or eplerenone in patients with LVEF ≤35% and symptomatic heart failure (NYHA class II-IV) 1
- Eplerenone specifically indicated post-MI with LV dysfunction and either heart failure or diabetes 1
- Critical contraindications: serum creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women), potassium >5.0 mEq/L, or estimated creatinine clearance <50 mL/min 1
- Monitor potassium closely due to serious hyperkalemia risk 1, 4
Diuretics:
- Loop diuretics for fluid overload management 1, 4
- Thiazide diuretics ineffective as monotherapy when GFR <30 mL/min 4
- Can combine thiazide with loop diuretics for resistant fluid overload 4
Nitrates:
- Long-acting nitrates for angina not controlled with beta-blockers 1
- Sublingual nitroglycerin for acute anginal episodes 1
- Do not use with phosphodiesterase inhibitors 1
Calcium Channel Blockers:
- Avoid in patients with LVEF <40%, especially non-dihydropyridines (diltiazem, verapamil) 1, 2
- Long-acting dihydropyridines (amlodipine) may be added only if angina or hypertension remains uncontrolled on other agents 1
Blood Pressure Management
- Target BP <130/80 mmHg in patients with ischemic cardiomyopathy 1
- Consider lowering to <120/80 mmHg if ventricular dysfunction present 1
- **Caution with diastolic BP <60 mmHg** - assess for myocardial ischemia symptoms, especially in patients >60 years or with diabetes 1
- Lower BP slowly in patients with elevated DBP and evidence of myocardial ischemia 1
Revascularization Strategy
Coronary Artery Bypass Grafting (CABG):
- Consider in patients with demonstrable myocardial viability and suitable coronary anatomy 2, 6, 7
- Optimal medical therapy combined with CABG shows improved long-term survival compared to medical therapy alone in appropriate candidates 5
- Assessment of myocardial viability using imaging techniques is crucial for clinical decision-making 6
Mitral Valve Intervention:
- In presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be performed at time of CABG 6
- Undersized mitral annuloplasty helpful for Carpentier type IIIb dysfunction 6
Left Ventricular Reconstruction:
- Surgery for LV shape and volume restoration may improve LV function in selected patients 6
Device Therapy
Implantable Cardioverter-Defibrillator (ICD):
- Class I indication: LVEF ≤30% at least 1 month post-MI and 3 months post-revascularization 1
- Class IIa indication: LVEF ≤35% with NYHA class II-III symptoms despite optimal medical therapy 1
- Do not implant until patient has been on optimal medical therapy and reassessed 2
Cardiac Resynchronization Therapy (CRT):
- Biventricular pacing indicated in NYHA class III-IV patients with LVEF ≤35%, QRS ≥130 ms, and LV end-diastolic diameter ≥55 mm despite optimal medical therapy 1
Lifestyle Modifications
- Medically supervised cardiac rehabilitation programs recommended at first diagnosis 1
- Resistance training at least 2 days per week 1
- Target BMI 18.5-24.9 kg/m² through balanced diet, exercise, and behavioral programs 1
- Sodium restriction particularly important in symptomatic heart failure 4
- Smoking cessation mandatory 1
- Avoid exposure to air pollution 1
Monitoring and Follow-Up
- Screen for depression and treat when indicated 1
- Monitor for atrial arrhythmias - these can exacerbate cardiomyopathy and require aggressive management 1, 2
- Assess volume status through physical examination and daily weight monitoring 4
- Renal function and electrolytes: check 1-2 weeks after medication changes, then at 3 months and every 6 months 4
Common Pitfalls to Avoid
- Delaying treatment in asymptomatic patients - ACE inhibitors and beta-blockers should be started even without symptoms 2
- Using wrong beta-blockers - only carvedilol, metoprolol succinate, or bisoprolol have proven mortality benefit 1, 2
- Inadequate beta-blocker dosing - must titrate to target doses 2
- Combining ACE inhibitors and ARBs - increases adverse events without benefit 1
- Using calcium channel blockers with negative inotropic effects in patients with LVEF <40% 1, 2
- Ignoring atrial arrhythmias - these worsen cardiomyopathy and require specific management 1, 2
- Thiazide monotherapy in advanced kidney disease (GFR <30 mL/min) - ineffective 4