Initial Treatment for Severely Reduced LV Systolic Function in Home Care
For a patient with severely reduced LV systolic function in the home care setting, starting with lisinopril 2.5 mg and metoprolol 12.5 mg daily is appropriate, with careful monitoring and gradual titration thereafter. 1, 2
Starting ACE Inhibitor Therapy
Begin with low-dose ACE inhibitor (lisinopril 2.5 mg daily) as the cornerstone of therapy, as ACE inhibitors improve ventricular function, reduce mortality, and are first-line treatment for systolic dysfunction. 1, 3
Pre-initiation Steps:
- Review and reduce diuretics 24 hours before starting the ACE inhibitor to avoid excessive hypotension. 4, 2
- Check baseline renal function (creatinine, GFR) and electrolytes (potassium, sodium). 1, 2
- Avoid potassium-sparing diuretics during ACE inhibitor initiation to prevent hyperkalemia. 2
Monitoring Schedule:
- Recheck blood pressure, renal function, and electrolytes 1-2 weeks after initiation and after each dose increment. 1, 2
- Continue monitoring at 3 months, then every 6 months. 1, 2
- Acceptable parameters: serum creatinine ≤2.5 mg/dL in men or ≤2.0 mg/dL in women, and potassium <5.0 mEq/L. 3
Starting Beta-Blocker Therapy
Initiate metoprolol 12.5 mg daily concurrently with the ACE inhibitor, as beta-blockers improve survival and reverse LV dysfunction in systolic heart failure. 4, 3
Key Considerations:
- Start at low doses and titrate gradually to avoid precipitating acute decompensation. 2
- Beta-blockers are particularly important as they may lead to better surgical outcomes and delayed onset of LV dysfunction. 4
- Do not withhold beta-blockers even in the presence of severely reduced ejection fraction, as they are Class I recommendations for symptomatic heart failure with reduced LVEF. 3
Titration Strategy
Gradually increase doses to target levels proven effective in large trials:
- Titrate lisinopril toward 20-40 mg daily (or maximum tolerated dose). 1
- Titrate metoprolol toward target doses used in clinical trials. 1
- Increase doses every 1-2 weeks as tolerated, monitoring blood pressure and symptoms. 1, 2
Diuretic Management
Add loop diuretics only if fluid overload is present (pulmonary congestion or peripheral edema). 4, 3
Critical Pitfall:
- Diuretics should always be administered in combination with ACE inhibitors, never as monotherapy. 2
- Avoid excessive diuresis, which can reduce preload and worsen cardiac output. 5, 2
- If GFR <30 mL/min, do not use thiazides except synergistically with loop diuretics. 2
Medications to Avoid
Explicitly avoid NSAIDs, as they cause sodium and water retention, counteract diuretic effects, and can precipitate acute decompensation even with single-dose exposure. 1
Avoid or withdraw:
Additional Considerations for Trace Tricuspid Regurgitation
The trace TR is likely secondary to LV dysfunction and may improve with optimization of LV function. 6
- Improvement in LVEF by more than 10% is the strongest predictor of reversible TR in patients with functional tricuspid regurgitation. 6
- Appropriate medical therapy including ACE inhibitors and beta-blockers should be optimized before considering any intervention for TR. 6
Monitoring for Clinical Response
- Assess for symptom improvement (dyspnea, exercise tolerance). 1, 2
- Monitor for signs of fluid retention: weight gain, peripheral edema, worsening dyspnea. 1
- Consider echocardiographic reassessment at 3-6 months to evaluate response to therapy and LV function improvement. 5, 2
Special Circumstances
If the patient develops intolerable cough or angioedema from lisinopril, switch to an ARB (such as losartan), which provides similar benefits with fewer side effects. 2, 3
For patients with moderately severe to severe symptoms who can be carefully monitored, consider adding an aldosterone antagonist once ACE inhibitor and beta-blocker are established. 3