When to consider ischemic workup in heart failure with reduced ejection fraction (HFrEF)?

From the Guidelines

Ischemic workup should be considered in all patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) as coronary artery disease is a common cause of HFrEF, and identifying and treating underlying coronary disease can improve outcomes. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, about half of acute and chronic HF patients have an ischemic etiology, and the evaluation of inducible ischemia is important in patients with HF. Specific situations that warrant urgent ischemic evaluation include patients presenting with angina, those with significant cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD), patients with regional wall motion abnormalities on imaging, and those with elevated cardiac biomarkers.

The initial workup typically includes a 12-lead ECG, cardiac biomarkers (troponin), and echocardiography. For definitive assessment, coronary angiography remains the gold standard, though non-invasive testing such as stress testing or coronary CT angiography may be appropriate for lower-risk patients 1. Exercise or pharmacological stress echocardiography can be used for the assessment of inducible ischemia and can also help in the differential diagnosis of HFpEF. Stress SPECT or PET can also be used for the detection of inducible ischemia.

In patients with HFrEF and moderate-to-severe inducible myocardial ischemia, surgical revascularization improved long-term survival 1. Additionally, medical therapy for ischemic cardiomyopathy includes standard guideline-directed medical therapy for HFrEF (beta-blockers, ACE inhibitors/ARBs/ARNI, MRAs, SGLT2 inhibitors) plus antiplatelet therapy and high-intensity statins. The rationale for aggressive ischemic workup is that identifying and treating underlying coronary disease can prevent further myocardial damage and potentially allow for myocardial recovery in areas of hibernating myocardium.

Key considerations in the workup and management of HFrEF include:

• Identifying and treating underlying coronary disease to improve outcomes
• Using non-invasive testing such as stress testing or coronary CT angiography for lower-risk patients
• Considering surgical revascularization for patients with moderate-to-severe inducible myocardial ischemia
• Implementing standard guideline-directed medical therapy for HFrEF plus antiplatelet therapy and high-intensity statins for ischemic cardiomyopathy.

From the Research

Ischemic Workup in HFrEF

When considering an ischemic workup for patients with heart failure with reduced ejection fraction (HFrEF), several factors come into play. The following points highlight the key considerations:

• HFrEF is a major public health concern with substantial morbidity and mortality, and its management has seen significant scientific breakthroughs in recent decades 2.
• The role of ischemic heart disease in the pathogenesis of HFrEF is crucial, and medical management strategies are available for this condition 3.
• Revascularization strategies, such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), have been shown to be superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction 4.
• The choice of method for myocardial revascularization should be discussed within an interdisciplinary cardiac team, considering the patient's symptoms, ischemic burden, coronary findings, perioperative risk, and current medical HF therapy 5.

Key Considerations for Ischemic Workup

The decision to perform an ischemic workup in HFrEF patients should be based on the following:

• Presence of ischemic cardiomyopathy as the cause of HFrEF or as an accompanying condition 5.
• Severity of coronary heart disease and the potential benefit of revascularization 4.
• Patient's symptoms, medical history, and current medical therapy 5.
• The potential role of CABG or PCI in improving survival and reducing morbidity in patients with HFrEF and ischemic heart disease 4.

Management Strategies

The management of HFrEF involves a combination of medical therapies, including:

• Neurohormonal modulation with beta blockers, angiotensin receptor-neprilysin inhibitors, and mineralocorticoid receptor antagonists 2, 6.
• Sodium glucose cotransporter 2 (SGLT2) inhibitors to improve outcomes in patients with HF regardless of their diabetic status 6.
• Additional approaches using ivabradine, hydralazine/isosorbide dinitrate, digoxin, and vericiguat as adjuncts to core therapies in selected patients 6.