What is the best course of management for a 64-year-old male patient with a history of edema, mildly depressed left ventricular global systolic function, and an estimated left ventricular ejection fraction of 45%, as indicated by a routine echocardiogram?

Management of Heart Failure with Mildly Reduced Ejection Fraction and Edema

This 64-year-old male with an LVEF of 45%, mild-to-moderate LV hypertrophy, abnormal diastolic function, and edema requires coronary angiography to exclude ischemic cardiomyopathy, followed by guideline-directed medical therapy for heart failure with mildly reduced ejection fraction (HFmrEF).

Immediate Diagnostic Priority: Rule Out Ischemic Etiology

Coronary angiography is the essential next step because this patient has regional wall motion abnormalities (equivocal distal septal and apical hypokinesis) with reduced ejection fraction, which mandates assessment of coronary anatomy 1. The American College of Cardiology recommends coronary angiography for patients with regional wall motion abnormalities and reduced ejection fraction to assess revascularization potential 1.

• The presence of regional wall motion abnormalities in the setting of new or worsening heart failure symptoms strongly suggests possible ischemic cardiomyopathy 1
• Echocardiography alone is insufficient for management decisions in new-onset cardiomyopathy when regional wall motion abnormalities exist 1
• Do not delay with additional non-invasive testing when regional dysfunction is present, as this only postpones definitive diagnosis and potential life-saving intervention 1

Addressing the Edema

The edema in this patient has a clear cardiac etiology given the echocardiographic findings of heart failure:

• This is NOT a case where echocardiography has low diagnostic yield - the patient has documented LV systolic dysfunction (EF 45%), LV hypertrophy, diastolic dysfunction, and mild LA enlargement 2
• The ACC/AHA guidelines state echocardiography is indicated (Class I) for edema with clinical signs of heart disease 2
• The abnormal diastolic function (lateral and medial mitral annular velocities of 0.06 m/sec) confirms diastolic dysfunction contributing to volume overload 2, 3

Guideline-Directed Medical Therapy for HFmrEF

Once ischemic disease is excluded or revascularized, initiate comprehensive heart failure therapy:

Core Medications (all have mortality benefit in reduced EF):

• ACE inhibitor or ARB: Essential for reducing mortality and preventing progression 1, 3
• Beta-blocker: Carvedilol, metoprolol succinate, or bisoprolol for mortality reduction 1
• Mineralocorticoid receptor antagonist (MRA): Spironolactone or eplerenone, particularly given the LV hypertrophy and diastolic dysfunction 3
• SGLT2 inhibitor: Dapagliflozin or empagliflozin - emerging evidence supports use even in mildly reduced EF 3

Diuretic Therapy for Volume Management:

• Loop diuretic (furosemide or torsemide) for symptomatic edema relief 3, 4
• Titrate to achieve euvolemia while monitoring renal function and electrolytes 3
• The goal is resolution of edema and dyspnea, not arbitrary diuretic dosing 3

Serial Monitoring Strategy

Repeat echocardiography is indicated after revascularization (if performed) and optimization of medical therapy:

• Reassess LVEF at 3 months after optimal medical therapy to determine ICD candidacy if EF remains ≤35% 1
• The ACC/AHA guidelines recommend serial echocardiography when there has been a documented change in clinical status or to guide medical therapy 2
• Monitor for improvement in diastolic function parameters and LA size as markers of treatment response 2

Critical Pitfalls to Avoid

Do not attribute edema to non-cardiac causes when the echocardiogram clearly shows cardiac dysfunction - this patient has documented heart failure 3, 5. The common error is assuming "mild" dysfunction doesn't cause symptoms, but an EF of 45% with diastolic dysfunction absolutely causes volume overload 3.

Do not skip coronary evaluation - regional wall motion abnormalities demand exclusion of ischemic disease, as revascularization could improve both symptoms and prognosis 1. Missing reversible ischemia is a critical error in this clinical scenario.

Do not undertitrate medications - maximize doses of ACE inhibitor/ARB and beta-blocker as tolerated by blood pressure and heart rate, as mortality benefit is dose-dependent 1.

Additional Metabolic Assessment

• Obtain lipid panel, HbA1c, and thyroid function if not already done, as these comorbidities affect heart failure outcomes 1
• Assess renal function closely as diuretics and RAAS inhibitors are initiated 4
• Consider BNP/NT-proBNP as baseline for future comparison and to guide diuretic therapy 3, 4