How should I manage a patient with an ejection fraction of approximately 40%, atrial fibrillation, moderate left atrial enlargement, mild right‑sided chamber enlargement, a 4.8 cm ascending aortic aneurysm, mild mitral and pulmonic regurgitation, trace tricuspid regurgitation, and no evidence of pulmonary hypertension?

Management of Heart Failure with Reduced Ejection Fraction, Atrial Fibrillation, and Ascending Aortic Aneurysm

This patient requires immediate initiation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), rate control for atrial fibrillation with anticoagulation, and cardiothoracic surgery consultation for the ascending aortic aneurysm exceeding 4.5 cm.

Heart Failure Management (EF 40%)

Classification and Prognosis

• An ejection fraction of 40% places this patient at the upper boundary of HFrEF (defined as LVEF ≤40%), which carries significant mortality risk but also substantial potential for recovery with optimal medical therapy 1, 2.
• The 5-year survival rate after hospitalization for HFrEF is only 25%, making aggressive medical management critical 2.
• Younger patients with atrial fibrillation and less severe left ventricular dilation have higher likelihood of EF recovery ("recovered EF"), which is associated with better prognosis 3.

Foundational Medical Therapy

Initiate the following medications immediately unless contraindicated 1, 4, 2:

• Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol): Start at low dose and titrate to target over 2-3 months. This is Class I indication with Level of Evidence A for all patients with current or prior heart failure symptoms and reduced LVEF 4. Beta-blockers provide mortality benefit (34% reduction with metoprolol succinate), promote reverse remodeling, and reduce mitral regurgitation severity 4.

• Angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan): Preferred over ACE inhibitors or ARBs as foundational therapy. In the PARADIGM-HF trial, sacubitril/valsartan reduced the composite endpoint of cardiovascular death or heart failure hospitalization by 20% (HR 0.80,95% CI 0.73-0.87, p<0.0001) and improved overall survival (HR 0.84,95% CI 0.76-0.93, p=0.0009) 5. Start after discontinuing ACE inhibitor with appropriate washout period.

• Mineralocorticoid receptor antagonist (MRA): Add for persistent symptoms after initiating beta-blocker and ARNI 1, 2.

• SGLT2 inhibitor: Recent breakthrough therapy that significantly reduces cardiovascular and all-cause mortality irrespective of diabetes status 2.

Monitoring and Reassessment

• Perform echocardiographic reassessment at 3-6 months to evaluate for EF recovery, LV remodeling, and mitral regurgitation severity reduction 4.
• Nearly 60% of patients with heart failure and secondary mitral regurgitation show significant improvement in MR severity after GDMT optimization 4.

Atrial Fibrillation Management

Rate Control Strategy

• Target heart rate <100 bpm at rest using beta-blockers (bisoprolol preferred) 6.
• Beta-blockers are the most effective agents for controlling ventricular response during atrial fibrillation, more effective than calcium channel blockers or digoxin 6.
• Avoid excessive bradycardia (heart rate <60 bpm), as this may worsen hemodynamics in the setting of mitral regurgitation by prolonging diastole 1, 4.
• If hypotension develops with beta-blocker, consider switching carvedilol to metoprolol or bisoprolol for less hypotensive effect, or spacing out medication timing 4.

Anticoagulation

• Initiate therapeutic anticoagulation immediately given atrial fibrillation with moderate left atrial enlargement (which increases thromboembolic risk) 6.
• Calculate CHA₂DS₂-VASc score to determine stroke risk and guide anticoagulation intensity.
• Direct oral anticoagulants (DOACs) are preferred over warfarin unless contraindicated.

Prognostic Implications

• Moderate left atrial enlargement indicates chronic atrial remodeling and carries important prognostic value independently of left ventricular ejection fraction 7.
• Left atrial dysfunction is common in systolic heart failure and contributes to development and progression of atrial fibrillation 7.

Ascending Aortic Aneurysm Management

Urgent Surgical Evaluation Required

• An ascending aortic diameter of 4.8 cm requires cardiothoracic surgery consultation for consideration of surgical repair 1.
• While specific guidelines for ascending aortic aneurysm thresholds vary, most recommend surgical intervention at 5.0-5.5 cm in asymptomatic patients, or earlier with rapid growth or connective tissue disorders.
• At 4.8 cm, this patient is approaching surgical threshold and requires close surveillance.

Medical Management Pending Surgery

• Strict blood pressure control is essential to reduce aortic wall stress and slow aneurysm progression.
• Beta-blockers serve dual purpose: heart failure management and reduction of aortic wall stress 1.
• Target systolic blood pressure <120 mmHg if tolerated.

Surveillance

• Serial imaging (CT or MRI) every 6 months to monitor aneurysm growth rate.
• Growth >0.5 cm per year is indication for earlier surgical intervention.

Valvular Disease Management

Mild Mitral Regurgitation

• The mild mitral regurgitation is likely secondary (functional) rather than primary, related to left ventricular dysfunction and atrial fibrillation 1.
• With EF 40% and mild MR, surgical intervention is not indicated 1.
• Optimize GDMT first, as this will likely reduce MR severity through reverse remodeling 4.
• If MR progresses to severe with persistent symptoms despite optimal medical therapy and LVEF remains >30%, consider transcatheter mitral edge-to-edge repair (TEER) 2.

Mild Pulmonic and Trace Tricuspid Regurgitation

• These mild degrees of right-sided valvular regurgitation do not require specific intervention 8.
• The absence of pulmonary hypertension by tricuspid regurgitation jet gradient is reassuring 1.
• Mild right-sided chamber enlargement likely reflects chronic atrial fibrillation and volume overload rather than primary right ventricular pathology 8.

Critical Pitfalls to Avoid

• Do not delay beta-blocker initiation despite EF of 40%: Even at this "borderline" EF, beta-blockers provide substantial mortality benefit and promote EF recovery 4, 3.

• Do not use digoxin as first-line rate control: It is the least effective agent for controlling ventricular response in atrial fibrillation 6.

• Do not allow LVEF to fall into the lower limit of normal range before intensifying therapy: Unlike aortic regurgitation, where surgery can be delayed until LVEF falls to 50%, heart failure management requires aggressive intervention at LVEF ≤40% 1.

• Do not discontinue anticoagulation prematurely: The highest risk of thromboembolism is in the first few months after atrial fibrillation diagnosis, particularly with left atrial enlargement 6.

• Do not attribute all symptoms to heart failure: With morbid obesity (if present), peripheral edema is multifactorial and predominantly related to obesity itself rather than mild tricuspid regurgitation 8.

• Do not ignore the ascending aortic aneurysm: At 4.8 cm, this requires active surveillance and surgical planning, as rupture or dissection carries catastrophic mortality 1.

Multidisciplinary Team Approach

• Cardiology: Optimize GDMT, manage atrial fibrillation, monitor for EF recovery.
• Cardiothoracic surgery: Evaluate ascending aortic aneurysm for surgical timing.
• Heart failure specialist: Consider advanced therapies if EF fails to improve despite optimal medical therapy.
• Electrophysiology: Consider catheter ablation for atrial fibrillation if rate control inadequate or patient remains highly symptomatic despite optimal rate control.