What is the significance of a reduced ejection fraction (EF) with basal inferior akinesis on echocardiogram in a patient with previously improved hypertensive urgency?

From the Guidelines

The patient's reduced ejection fraction with basal inferior akinesis requires immediate initiation of guideline-directed medical therapy for heart failure with reduced ejection fraction, including an ACE inhibitor, a beta-blocker, and potentially a mineralocorticoid receptor antagonist, as recommended by the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. The patient's hypertensive urgency has improved, but the echocardiogram showing reduced ejection fraction (EF) with basal inferior akinesis indicates significant cardiac damage that requires prompt management.

• The basal inferior akinesis suggests a prior myocardial infarction affecting the inferior wall, likely supplied by the right coronary artery.
• This patient should be referred for cardiac catheterization to evaluate for coronary artery disease, as revascularization may improve outcomes, as suggested by the European Heart Journal in 2017 1.
• Additionally, diuretics like furosemide 20-40mg daily may be needed if fluid overload is present.
• Close monitoring of blood pressure, renal function, and electrolytes is essential, particularly during medication initiation and dose adjustments.
• Lifestyle modifications including sodium restriction (<2g/day), fluid restriction if symptomatic, regular physical activity as tolerated, and smoking cessation are also crucial components of management, as outlined in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The reduced EF and wall motion abnormality indicate myocardial damage that may lead to heart failure symptoms, arrhythmias, and increased mortality risk if not properly treated.
• The use of antiarrhythmic drugs, such as beta-blockers and amiodarone, or catheter ablation should be considered in patients with a low ejection fraction and persistently high frequency of ventricular ectopic beats, as recommended by the European Heart Journal in 2017 1.
• Achieving adequate BP control and promoting LVH regression is a central management goal, and any combination of antihypertensive drug classes should be considered as needed to achieve this goal, as discussed in the European Heart Journal in 2017 1.

From the Research

Hypertensive Urgency and Reduced Ejection Fraction

• The patient's condition has improved from hypertensive urgency, but an echo showed reduced ejection fraction (EF) with basal inferior akinesis, indicating potential heart failure with reduced ejection fraction (HFrEF) 2.
• Reduced EF is a significant predictor of heart failure and myocardial remodeling, and the ACE2-Ang (1-7)-Mas receptor axis may play a protective role in preventing myocardial remodeling in HFrEF with hypertension 3.

Treatment Options for Heart Failure with Reduced Ejection Fraction

• Angiotensin receptor-neprilysin inhibitors (ARNI) have been shown to be superior to angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) in reducing the risk of all-cause mortality, cardiac death, and major adverse cardiac events in patients with HFrEF 4.
• However, ARNI is associated with a higher risk of hypotension compared to ACE-I and ARB 4.

Ejection Fraction and Heart Failure

• Ejection fraction (EF) is a valuable diagnostic and prognostic tool for heart failure, but its use has limitations, particularly in detecting subclinical left ventricular dysfunction and recognizing changes in left ventricular function on sequential testing 5.
• Patients with reduced EF, including those with HFrEF, can benefit from cardiac rehabilitation, which can improve their lipid profile, physical fitness, and reduce the risk of clinical events 6.

Management and Outcomes of Patients with Reduced Ejection Fraction

• Patients with reduced EF, including those with HFrEF, often have comorbidities such as diabetes mellitus and are more likely to have risk factors for heart failure 6.
• Management of patients with reduced EF should focus on optimizing medical therapy, including the use of ARNI, ACE-I, or ARB, as well as lifestyle modifications, such as regular physical activity and dietary changes 4, 6.