From the Guidelines
For a 71-year-old male with exertional dyspnea, reduced ejection fraction (40-45%), and no significant coronary artery disease, I recommend starting guideline-directed medical therapy for heart failure with reduced ejection fraction, as outlined in the European Society of Cardiology quality indicators for the care and outcomes of adults with heart failure 1.
Initial Treatment
Begin with an ACE inhibitor like lisinopril 5-10mg daily or an ARB such as losartan 25-50mg daily, along with a beta-blocker such as carvedilol 3.125mg twice daily or metoprolol succinate 25mg daily, titrating doses upward as tolerated.
Additional Therapies
Consider adding a mineralocorticoid receptor antagonist like spironolactone 25mg daily if symptoms persist, as well as a sodium–glucose co-transporter 2 (SGLT2) inhibitor, which has been shown to improve prognosis in patients with HF with reduced ejection fraction 1.
Evaluation and Lifestyle Modifications
Additional evaluation should include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Iron studies
- NT-proBNP levels to identify potential reversible causes of heart failure An MRI with gadolinium could help determine if there's an infiltrative cardiomyopathy, myocarditis, or other structural heart disease. Lifestyle modifications including:
- Sodium restriction (<2g/day)
- Fluid restriction if needed
- Regular moderate exercise
- Smoking cessation are essential. This approach addresses the likely non-ischemic cardiomyopathy by optimizing cardiac function through neurohormonal modulation while investigating potential underlying causes.
Referral to a Specialist
Consider referral to a specialist if the patient has high-risk features, such as persistent NYHA functional class III–IV symptoms, or if there is a need for further evaluation and consideration of advanced therapies, as outlined in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1.
From the FDA Drug Label
The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF) Patients had to have been on an ACE inhibitor or ARB for at least four weeks and on maximally tolerated doses of beta-blockers. Patients with a systolic blood pressure of less than 100 mmHg at screening were excluded The mean left ventricular ejection fraction was 29%. PARADIGM-HF demonstrated that sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to and RAS inhibitor (enalapril), in reducing the risk of the combined endpoint of cardiovascular death or hospitalization for heart failure, based on a time-to-event analysis (hazard ratio [HR] 0.80; 95% confidence interval [CI], 0.73,0.87, p <0. 0001).
The patient has reduced left ventricular function (40-45%) and symptoms of heart failure, such as shortness of breath with exertion.
- The patient does not have significant coronary artery disease.
- Consideration can be given to initiating sacubitril and valsartan as it has been shown to be superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure in patients with symptomatic chronic heart failure and systolic dysfunction 2.
- It is essential to ensure the patient is on maximally tolerated doses of beta-blockers and has been on an ACE inhibitor or ARB for at least four weeks before initiating sacubitril and valsartan.
- The patient's systolic blood pressure should be monitored to ensure it is not less than 100 mmHg before starting sacubitril and valsartan.
From the Research
Medical Management
The patient's condition, with reduced ejection fraction of 40-45% and no significant coronary artery disease, suggests heart failure with reduced ejection fraction (HFrEF) 3, 4, 5, 6, 7. The following medical management options can be considered:
- Angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) to reduce mortality and morbidity 3, 4, 5, 6
- Beta blockers to improve survival and reduce hospitalizations 3, 4, 5, 7
- Direct-acting vasodilators, aldosterone antagonists, and diuretics as needed for symptom control 3
- Consideration of newer medications such as angiotensin receptor blocker/neprilysin inhibitor (ARNI) and sodium-glucose cotransporter 2 (SGLT2) inhibitors for additional benefits 4, 6
Device Therapy
For selected patients with HFrEF, device therapy may be beneficial:
- Implantable cardioverter-defibrillators to improve mortality and function 3, 7
- Biventricular pacemakers (cardiac resynchronization therapy) to improve function and reduce hospitalizations 3, 7
Disease Management
To reduce hospitalizations and mortality, consider: