Initial Management of Global Left Ventricular Hypokinesia
First-Line Pharmacological Therapy
- The American College of Cardiology recommends ACE inhibitors for all patients with LV dysfunction unless contraindicated 1
- Beta blockers proven to reduce mortality, such as bisoprolol, carvedilol, or sustained-release metoprolol succinate, should be initiated in all stable patients with LV dysfunction 1, 2
- Diuretics and salt restriction are indicated in patients with evidence of fluid retention 1
- Angiotensin II receptor blockers are recommended as alternatives for patients who are ACE inhibitor-intolerant 2
Additional Pharmacological Considerations
- Aldosterone antagonists should be added in patients with moderately severe to severe symptoms and reduced LVEF who can be monitored for renal function and potassium levels 1
- For African American patients with moderate to severe symptoms, the combination of hydralazine and nitrates is recommended in addition to standard therapy 1
- Certain medications, including NSAIDs, most antiarrhythmic drugs, and most calcium channel blockers, should be avoided as they can worsen LV dysfunction 1
Device Therapy Considerations
- An implantable cardioverter-defibrillator should be considered for primary prevention in patients with LVEF ≤35% and NYHA class II-III symptoms despite optimal medical therapy 1, 2
- Cardiac resynchronization therapy should be considered for patients with LVEF ≤35%, sinus rhythm, QRS duration ≥0.12 seconds, and NYHA class III or ambulatory class IV symptoms despite optimal medical therapy 1
Monitoring and Follow-up
- Exercise training should be considered as an adjunctive approach to improve clinical status in ambulatory patients with LV dysfunction 1