What is the best management approach for a patient with a reduced ejection fraction (EF) of 30%, indicating severe left ventricular dysfunction?

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

For a patient with an ejection fraction of 30%, you must immediately initiate quadruple guideline-directed medical therapy (GDMT) consisting of: (1) ACE inhibitor or ARNI, (2) evidence-based beta-blocker, (3) mineralocorticoid receptor antagonist, and (4) SGLT2 inhibitor—all started together without delay, as this combination reduces mortality and hospitalization more effectively than sequential therapy. 1, 2

Pharmacological Therapy: The Four Pillars

First-Line Therapy (Start All Four Classes)

ACE Inhibitor or ARNI:

• Start with an ACE inhibitor (lisinopril 5 mg daily, titrate to 20-35 mg daily) as the evidence base is stronger than ARBs 3
• The ATLAS trial demonstrated that higher doses (35 mg lisinopril) had outcomes at least as favorable as lower doses in systolic heart failure 4
• Consider switching to sacubitril/valsartan (ARNI) after ACE inhibitor stabilization, as ARNI provides superior NT-proBNP reduction and clinical outcomes 1, 5
• Only switch from ACE inhibitor to ARB if adverse effects are intolerable 3
• Monitor renal function and potassium closely 3

Evidence-Based Beta-Blocker:

• Use only bisoprolol, carvedilol, metoprolol succinate, or nebivolol—these are the only beta-blockers with proven mortality benefit in heart failure 3
• Beta-blockers reduce mortality by approximately 35% and specifically reduce sudden cardiac death 1
• Start at low doses and titrate to target doses 1, 2

Mineralocorticoid Receptor Antagonist (MRA):

• Add spironolactone 12.5-25 mg daily (maximum 50 mg) for patients already on ACE inhibitor and beta-blocker 3, 1
• MRAs reduce mortality and sudden death 1
• Requires close monitoring of potassium levels and renal function 3

SGLT2 Inhibitor:

• Initiate an SGLT2 inhibitor with proven cardiovascular benefit to reduce cardiovascular events, independent of diabetes status 1
• This is now a Class I recommendation and should not be delayed 1, 2

Device Therapy Evaluation

Implantable Cardioverter-Defibrillator (ICD):

• Your patient with EF 30% qualifies for ICD therapy for primary prevention of sudden cardiac death 3, 1
• The indication is LVEF ≤30% with NYHA class I symptoms on GDMT, or LVEF ≤35% with NYHA class II-III symptoms 3, 1
• Must be at least 40 days post-MI if ischemic cardiomyopathy 3
• Requires reasonable expectation of meaningful survival >1 year 3, 1
• Additionally, with EF 30%, check ECG for QRS duration ≥120 ms, which would make ICD indication even stronger 3

Cardiac Resynchronization Therapy (CRT):

• Obtain 12-lead ECG to assess QRS duration 3, 1
• If QRS ≥150 ms with left bundle branch block pattern and patient remains symptomatic despite GDMT, CRT is indicated 3, 1
• CRT criteria: LVEF <35%, QRS ≥150 ms, or QRS 120-149 ms with mechanical dyssynchrony on echocardiography 3

Revascularization Considerations

Coronary Artery Disease Assessment:

• With EF 30%, you must evaluate for ischemic etiology through stress testing or coronary angiography 3, 1
• If multivessel coronary artery disease is present, CABG is recommended over medical therapy alone to improve long-term survival in surgically eligible patients with LVEF ≤35% 3, 1
• Use intracoronary pressure measurement (FFR or iFR) to guide lesion selection in multivessel disease 3, 1
• Heart Team discussion is mandatory when considering revascularization options 3, 1

Additional Therapies

Diuretics:

• Add loop diuretics (furosemide 20-40 mg once or twice daily, maximum 600 mg) if fluid retention is present 3
• Titrate to achieve euvolemia, not to a specific dose 3

Exercise Rehabilitation:

• Offer supervised group exercise-based rehabilitation program with psychological and educational components once patient is stable 3
• Exercise rehabilitation reduces hospital admissions and increases long-term quality of life 3

Monitoring Strategy

Serial Assessments:

• Monitor renal function and electrolytes closely, especially when initiating or uptitrating ACE inhibitors, ARBs, or MRAs 3
• Consider specialist monitoring of serum natriuretic peptide levels (BNP/NT-proBNP) to guide therapy uptitration 3
• Repeat echocardiography every 6-12 months to assess for reverse remodeling 1, 6

Critical Pitfalls to Avoid

Clinical Inertia:

• Do not delay initiation of all four GDMT classes—start them together, not sequentially 7, 2
• Real-world data shows only 18-22% of patients achieve target ARNI doses with usual care, but 60.9% achieve target with pharmacist-led programs 7, 8
• Up to 50% of patients are undertreated for unknown reasons, suggesting clinical inertia 9

Medication Errors:

• Never use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with LVEF <40% due to negative inotropic effects 3, 1
• Avoid NSAIDs as they adversely affect clinical status in heart failure 3
• Do not routinely combine ACE inhibitor, ARB, and aldosterone antagonist together 3

Underdosing:

• Hypotension, bradycardia, kidney dysfunction, and hyperkalemia are common barriers, but aggressive uptitration with close monitoring improves outcomes 9
• Target doses matter: higher doses of ACE inhibitors (35 mg lisinopril) show better outcomes 4
• Aim for ≥50% of target doses for all GDMT medications 9

Device Therapy Delays:

• Do not wait to refer for ICD evaluation—with EF 30%, the patient already meets criteria 3, 1
• Obtain ECG immediately to assess for CRT candidacy 3, 1