What is the best course of treatment for a patient with a significantly declined left ventricular ejection fraction (LVEF) of 30-35%, atrial fibrillation, and mild regurgitation of the mitral and tricuspid valves, who has experienced a decline in cardiac function from a previous LVEF of 50-55%?

Management of Significantly Declined LVEF with Atrial Fibrillation

This patient requires immediate initiation of guideline-directed medical therapy (GDMT) with ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, along with consideration for cardiac resynchronization therapy (CRT) if QRS criteria are met, and an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death. 1, 2

Immediate Pharmacological Management

Foundational Neurohormonal Blockade

• ACE inhibitors or ARBs must be initiated immediately in all patients with LVEF ≤35% to reduce total mortality and sudden cardiac death 2, 3
• Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) are essential and serve dual purposes: heart failure management and rate control for atrial fibrillation 2, 4
  • Beta-blockers are the first-line agents for rate control in patients with atrial fibrillation and reduced ejection fraction 4
  • Target resting heart rate <110 bpm initially 4
  • Start with low doses and titrate carefully to avoid hypotension and bradycardia 4

Additional Disease-Modifying Therapy

• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) should be added to the regimen, as they provide significant mortality benefit with minimal blood pressure effects 3
• SGLT2 inhibitors should be initiated early, as they provide mortality benefit with minimal blood pressure-lowering effects and reduce cardiovascular events independent of diabetes status 2, 3

Critical Medication to Avoid

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are contraindicated in patients with LVEF ≤40% due to their negative inotropic effects that may worsen heart failure 2, 4

Volume Management

• Loop diuretics should be used to manage volume overload and reduce ventricular filling pressure, with doses adjusted based on daily weights and clinical signs of congestion 3

Device Therapy Considerations

Implantable Cardioverter-Defibrillator (ICD)

This patient meets Class I indication for ICD therapy given LVEF of 30-35% 1, 2:

• ICD is recommended for primary prevention of sudden cardiac death in patients with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT who have reasonable expectation of meaningful survival >1 year 1
• The decision should be made at least 40 days post-MI if ischemic etiology, and after optimization of GDMT 1

Cardiac Resynchronization Therapy (CRT)

CRT eligibility depends on QRS duration and morphology, which is not provided in this echocardiogram report 1, 2:

If Patient Has Sinus Rhythm (Currently in AFib, but rhythm may vary):

• Class I indication: LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, and NYHA class II-IV symptoms 1
• Class IIa indication: LVEF ≤35%, sinus rhythm, non-LBBB pattern with QRS ≥150 ms, and NYHA class III/ambulatory IV symptoms 1

For This Patient with Atrial Fibrillation:

• CRT can be useful (Class IIa) in patients with AFib and LVEF ≤35% on GDMT if: 1, 2

  • The patient requires ventricular pacing or otherwise meets CRT criteria, AND
  • AV nodal ablation or pharmacological rate control allows near 100% ventricular pacing with CRT 1, 2

• The critical requirement is achieving ≥90-95% biventricular pacing 2

• AFib with rapid ventricular conduction is the leading cause of inadequate biventricular pacing 2

• If pharmacologic rate control fails to achieve ≥90-95% biventricular pacing, AV junction ablation should be performed 2

Management of Atrial Fibrillation

Rate Control Strategy

• Beta-blockers serve as both heart failure therapy and rate control 4
• Target heart rate <110 bpm initially 4
• Monitor biventricular pacing percentage at every follow-up if CRT is implanted, with target ≥90-95% 2

Anticoagulation

• Assess stroke risk using CHA₂DS₂-VASc score and initiate anticoagulation as indicated 4

Assessment for Revascularization

Given the significant decline in LVEF from 50-55% to 30-35%, coronary artery disease must be evaluated 1:

Indications for Coronary Assessment

• The rapid decline in LVEF suggests possible ischemic etiology 1
• Heart Team evaluation is recommended to choose between revascularization or medical therapy alone after careful evaluation of: 1
  • Coronary anatomy
  • Correlation between coronary artery disease and LV dysfunction
  • Comorbidities
  • Life expectancy
  • Individual risk-to-benefit ratio
  • Patient perspectives

If Multivessel CAD is Present

• In surgically eligible patients with multivessel CAD and LVEF ≤35%, myocardial revascularization with CABG is recommended over medical therapy alone to improve long-term survival 1
• Intracoronary pressure measurement (FFR or iFR) should guide lesion selection for intervention in patients with multivessel disease 1

Monitoring Parameters

Short-Term Monitoring (1-2 weeks after each dose increment)

• Renal function and electrolytes 3
• Blood pressure and heart rate 3

Regular Ongoing Assessment

• Symptoms and functional capacity 3
• Signs of volume overload requiring diuretic adjustment 3
• Repeat echocardiography to assess response to therapy 3
• If CRT implanted: biventricular pacing percentage at every follow-up 2

Addressing the Valve Regurgitation

Mild Mitral and Tricuspid Regurgitation

• The mild regurgitation noted is likely secondary to ventricular dilation and atrial enlargement rather than primary valve disease 1
• These typically improve with optimization of heart failure therapy and reduction in ventricular volumes 1
• Transcatheter mitral valve repair is reserved for severe secondary mitral regurgitation in high-risk patients, not applicable here 5

Common Pitfalls to Avoid

1. Using diltiazem or verapamil for rate control despite their effectiveness, as they worsen heart failure in patients with LVEF <40% 2, 4
2. Delaying device therapy while waiting for "optimal" medical therapy—GDMT optimization and device evaluation should proceed in parallel 1
3. Implanting CRT in AFib patients without a plan to ensure adequate biventricular pacing—this requires either excellent rate control or AV nodal ablation 2
4. Avoiding NSAIDs, as they worsen renal function and counteract beneficial effects of heart failure medications 3
5. Failing to assess for ischemic etiology given the significant decline in LVEF, which may indicate need for revascularization 1

Prognostic Considerations

• The decline from LVEF 50-55% to 30-35% represents a significant worsening with substantial implications for mortality and morbidity 5
• Five-year survival rate after hospitalization for HFrEF is approximately 25%, underscoring the importance of aggressive, comprehensive therapy 5
• The presence of atrial fibrillation is an independent risk factor for mortality from refractory heart failure, but this mortality gap can be eliminated with appropriate management including AV junction ablation if CRT is indicated and adequate biventricular pacing cannot otherwise be achieved 2