What is the management plan for a patient with heart failure with reduced ejection fraction (HFrEF), severe left ventricular systolic dysfunction, mild right ventricular dysfunction, moderate to severe tricuspid regurgitation, and elevated pulmonary artery systolic pressure?

Management of Heart Failure with Reduced Ejection Fraction and Right Ventricular Dysfunction

This patient requires immediate initiation of quadruple guideline-directed medical therapy (GDMT) consisting of SGLT2 inhibitor, ACE inhibitor/ARNI, beta-blocker, and mineralocorticoid receptor antagonist, along with loop diuretics for congestion, with careful attention to the moderate-to-severe tricuspid regurgitation and elevated pulmonary pressures that significantly worsen prognosis. 1, 2

Immediate Pharmacotherapy Initiation

Core Four-Pillar GDMT Strategy

Start all four medication classes simultaneously using a specific sequencing approach:

• Day 1-3: Begin SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) and mineralocorticoid receptor antagonist (spironolactone 12.5-25 mg daily) - these have minimal blood pressure effects and provide rapid mortality benefit 2, 3

• Day 3-7: Add low-dose beta-blocker (carvedilol 3.125 mg twice daily, bisoprolol 1.25 mg daily, or metoprolol succinate 12.5-25 mg daily) if heart rate >70 bpm and blood pressure tolerates 2, 4

• Day 7-14: Initiate ACE inhibitor (enalapril 2.5 mg twice daily) or preferably ARNI (sacubitril/valsartan 24/26 mg twice daily) after ensuring 36-hour washout from any prior ACE inhibitor 1, 5

• Loop diuretics (furosemide 40-80 mg daily initially) for the small pericardial effusion and any volume overload, adjusted based on daily weights and symptoms 2

Titration Protocol

Uptitrate one medication at a time every 1-2 weeks to target doses: 2

• Carvedilol target: 25-50 mg twice daily 2
• Bisoprolol target: 10 mg daily 2
• Metoprolol succinate target: 200 mg daily 2
• Enalapril target: 10-20 mg twice daily 2
• Sacubitril/valsartan target: 97/103 mg twice daily 5
• Spironolactone target: 25-50 mg daily (if potassium and renal function permit) 2

Critical Monitoring Parameters

Check the following at baseline and 1-2 weeks after each medication change: 2

• Blood pressure and heart rate at each visit
• Serum potassium and creatinine (particularly critical with MRA and ACE inhibitor/ARNI combination)
• Complete metabolic panel including BUN
• Daily weights for diuretic adjustment
• Symptoms of hypotension (dizziness, lightheadedness, syncope)

Acceptable ranges during titration: 2

• Systolic BP >90 mmHg (can tolerate 85-90 mmHg if asymptomatic)
• Potassium <5.5 mEq/L
• Creatinine increase <30% from baseline or <0.5 mg/dL absolute increase

Management of Right Ventricular Dysfunction and Tricuspid Regurgitation

Hemodynamic Optimization

The moderate-to-severe tricuspid regurgitation with RVSP 46 mmHg and TAPSE 1.6 cm indicates significant RV dysfunction that independently predicts worse outcomes: 6, 7, 8

• Optimize volume status carefully - avoid excessive diuresis that can reduce RV preload and cardiac output, but also avoid volume overload that worsens TR 9, 10

• Target euvolemia using daily weights, jugular venous pressure assessment, and peripheral edema monitoring 9

• The RV dysfunction is likely secondary to LV dysfunction and elevated filling pressures rather than primary pulmonary vascular disease, given the clinical context 7, 9

Prognostic Implications

The combination of severe LV dysfunction (EF 30-35%), RV dysfunction (TAPSE 1.6 cm, RV fractional area 35%), and moderate-to-severe TR carries significantly increased mortality risk: 6, 7, 8

• One-year survival with moderate-to-severe TR is approximately 64-79% even with optimal medical therapy 8
• RV dysfunction is independently associated with increased cardiovascular mortality (HR 1.85) and HF hospitalization (HR 1.99) 6
• The elevated right atrial pressure (15 mmHg) indicates advanced disease requiring aggressive GDMT 9, 10

Device Therapy Considerations

Evaluate for cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillator (ICD) once on stable GDMT: 1

• Obtain 12-lead ECG to assess QRS duration and morphology - CRT is indicated if QRS ≥150 ms with LBBB pattern and LVEF ≤35% 1
• ICD for primary prevention is indicated if LVEF remains ≤35% after 3 months of optimal medical therapy and life expectancy >1 year 1
• The prominent LV apical trabeculations warrant evaluation for left ventricular non-compaction cardiomyopathy, which may have additional ICD indications 1

Specialty Referral Criteria

Refer to advanced heart failure specialist if: 1

• Unable to uptitrate GDMT due to persistent hypotension (SBP <85 mmHg with symptoms) despite optimization attempts 2
• Recurrent HF hospitalizations despite optimal medical therapy 1
• Progressive decline in functional status to NYHA class IV 1
• Development of cardiogenic shock or need for inotropic support 1
• Consideration for advanced therapies (LVAD, cardiac transplantation) if consistent with patient goals 1

Common Pitfalls to Avoid

Never discontinue GDMT for asymptomatic hypotension - systolic BP 85-95 mmHg without symptoms is acceptable and associated with better long-term outcomes 2

Avoid NSAIDs completely - they interfere with ACE inhibitor efficacy, worsen renal function, and promote fluid retention 2

Do not defer SGLT2 inhibitor initiation - these should be started immediately as they provide benefit regardless of blood pressure and have rapid onset of mortality reduction 3

Never use thiazide diuretics if eGFR <30 mL/min/1.73m² unless combined synergistically with loop diuretics 2

Avoid excessive diuresis before starting ACE inhibitors/ARNI - this can precipitate hypotension and acute kidney injury 2

Do not assume TR will improve with medical therapy alone - while GDMT optimization is essential first-line treatment, moderate-to-severe TR may require interventional therapy if it persists despite optimal medical management 3

Additional Considerations

The small pericardial effusion requires monitoring but is likely related to the heart failure state and should improve with diuretic therapy 1

Screen for underlying etiologies: 1

• Ischemic evaluation (stress test or coronary angiography) if not previously performed
• Consider cardiac MRI to evaluate the prominent LV apical trabeculations and assess for infiltrative disease, myocarditis, or non-compaction cardiomyopathy
• Thyroid function testing (TSH already recommended at baseline) 2

Lifestyle modifications: 1

• Sodium restriction to <2-3 grams daily
• Fluid restriction to 1.5-2 liters daily if hyponatremic
• Daily weight monitoring with instructions to call if weight increases >2-3 pounds in 1 day or >5 pounds in 1 week
• Cardiac rehabilitation referral once stable 2