In a patient with multiple coronary artery stents and an echocardiogram showing a left ventricular ejection fraction (LVEF) of about 40%, what is the recommended management?

Management of LVEF 40% in a Patient with Multiple Coronary Stents

This patient requires immediate initiation of comprehensive four-pillar guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), as an LVEF of 40% places them at the threshold where neurohormonal blockade provides proven mortality benefit. 1, 2

Immediate Pharmacologic Management

Four-Pillar GDMT (Start All Simultaneously)

Initiate all four medication classes immediately or in rapid sequence—do not delay awaiting symptom development, as early treatment reduces mortality and prevents progression to overt heart failure. 2, 3

• Start sacubitril/valsartan (ARNI) as first-line RAAS inhibition at 24/26 mg twice daily, titrating to target dose of 97/103 mg twice daily over 3–6 weeks, because it provides superior reductions in cardiovascular mortality and heart failure hospitalization compared to ACE inhibitors or ARBs. 1, 2, 4

• If sacubitril/valsartan is unavailable or unaffordable, substitute an ACE inhibitor (enalapril, lisinopril, or ramipril) titrated to maximally tolerated doses. 1, 2

• Begin a guideline-recommended β-blocker (carvedilol, metoprolol succinate, or bisoprolol) concurrently with RAAS inhibition, targeting a resting heart rate of 50–60 bpm or the highest tolerated dose, because β-blockers reduce mortality in all patients with LVEF ≤40% regardless of symptom status. 1, 2, 3

• Add a mineralocorticoid receptor antagonist (spironolactone 12.5–25 mg daily or eplerenone 25–50 mg daily) if LVEF remains ≤35% after initial therapy, provided eGFR ≥30 mL/min/1.73 m² and serum potassium ≤5.0 mmol/L. 1, 2

• Prescribe an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) irrespective of diabetes status, as this class reduces cardiovascular mortality, all-cause mortality, and heart failure hospitalization across the full spectrum of reduced ejection fraction. 2, 3, 5

Antiplatelet Therapy for Stented Patients

• Continue dual antiplatelet therapy (DAPT) with aspirin 81 mg daily plus clopidogrel 75 mg daily for the duration recommended by stent type: 6–12 months for drug-eluting stents, 1 month for bare-metal stents, because premature discontinuation increases stent thrombosis risk. 1

• After completing the DAPT period, continue aspirin 81 mg daily indefinitely as secondary prevention. 1

Additional Symptomatic Management

• Use loop diuretics (furosemide, torsemide, or bumetanide) only if signs of congestion are present (elevated jugular venous pressure, pulmonary crackles, peripheral edema), titrating to the lowest dose that maintains euvolemia. 2

• Do not withhold β-blockers in stable patients with mild volume overload; instead optimize diuretic therapy, as β-blocker mortality benefit outweighs modest congestion. 2

Monitoring Strategy

• Schedule outpatient follow-up every 3–6 months initially to assess symptom emergence, medication tolerance, blood pressure, renal function (creatinine, eGFR), and serum potassium. 2, 3

• Check potassium and creatinine at 3 days, 1 week, then monthly for three months after starting the mineralocorticoid receptor antagonist to detect life-threatening hyperkalaemia. 2

• Repeat transthoracic echocardiography every 6–12 months to track LVEF trajectory, ventricular dimensions, and identify either improvement (HFimpEF, LVEF >40%) or progression to more severe HFrEF (LVEF <35%). 2, 3

• Measure BNP or NT-proBNP at baseline and serially to confirm diagnosis, stratify prognosis, and monitor treatment response; markedly elevated values confer diagnostic certainty. 2

Device Therapy Considerations

• Implantable cardioverter-defibrillator (ICD) for primary prevention is indicated if LVEF remains ≤35% after ≥3 months of optimal GDMT, provided the patient is ≥40 days post-myocardial infarction (ischemic cardiomyopathy) or has non-ischemic cardiomyopathy with expected survival >1 year and NYHA class II–III symptoms. 2

• Cardiac resynchronization therapy (CRT-D or CRT-P) is indicated if LVEF remains ≤35% with sinus rhythm, left bundle branch block, QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT. 2

• Re-evaluate LVEF after 3–6 months of optimal medical therapy before making device decisions, as some patients will improve above the 35% threshold. 3

Revascularization Assessment

• Evaluate for residual ischemia or incomplete revascularization using stress testing (if feasible) or coronary angiography, because patients with LVEF ≤35% and multivessel disease may benefit from additional revascularization (CABG preferred over PCI) to improve long-term survival. 1

• Involve a Heart Team (interventional cardiology, cardiac surgery, non-interventional cardiology) to define the optimal treatment strategy when considering further revascularization, particularly when CABG and PCI hold similar levels of recommendation. 1

Critical Pitfalls to Avoid

• Never rely on a single LVEF measurement for definitive therapeutic decisions; confirm with repeat imaging at 3–6 months to prevent misclassification due to measurement variability. 2, 3

• Do not postpone GDMT awaiting symptom development; early treatment in asymptomatic or mildly symptomatic LV dysfunction reduces mortality and prevents progression to overt heart failure. 2, 3

• Do not discontinue GDMT if LVEF improves above 40% (HFimpEF); maintain full four-pillar therapy indefinitely, as abrupt discontinuation leads to relapse of LV dysfunction and clinical heart failure. 2, 3

• Do not prescribe mineralocorticoid receptor antagonists when eGFR <30 mL/min/1.73 m² or serum potassium >5.0 mmol/L, due to risk of life-threatening hyperkalaemia. 2

• Do not combine ACE inhibitors with ARBs or sacubitril/valsartan, as dual RAAS blockade increases adverse events without additional benefit. 1