Management of Decreased Systolic Function

Pharmacological Management

The American College of Cardiology recommends ACE inhibitors and beta-blockers as first-line therapy for all patients with decreased systolic function, regardless of symptom severity 1, 2, 3
ACE inhibitors should be started in all patients with reduced left ventricular ejection fraction (LVEF) and titrated up to target doses used in clinical trials, with monitoring of renal function and potassium levels 1, 2, 4, 5
Beta-blockers should be initiated in all patients with reduced LVEF, regardless of symptom severity, using a "start-low, go-slow" approach with careful monitoring of heart rate, blood pressure, and clinical status 1, 2, 3
Diuretics are essential for symptomatic treatment when fluid overload is present and should be used in combination with ACE inhibitors when possible, with moderate sodium restriction and daily weight monitoring 2, 3, 4, 5
Angiotensin Receptor Blockers (ARBs) are reasonable alternatives to ACE inhibitors, but not recommended to routinely combine with ACE inhibitors due to increased risk of hyperkalemia 1, 2, 3
Aldosterone antagonists should be added in selected patients with moderately severe to severe symptoms, with monitoring of renal function and potassium levels 2, 3

Cardiac Resynchronization Therapy (CRT) is recommended for patients with LVEF ≤35%, sinus rhythm, and QRS duration >0.12 ms, with NYHA class III or ambulatory class IV symptoms despite optimal medical therapy 2, 3
Implantable Cardioverter-Defibrillator (ICD) should be considered for primary prevention in patients with LVEF ≤30%, with NYHA class II-III symptoms despite optimal medical therapy, and a reasonable expectation of survival with good functional status for >1 year 2, 3

Physical activity should be encouraged in stable patients, with avoidance of restriction of activity that promotes deconditioning, and consideration of formal exercise training programs for stable NYHA II-III patients 2, 3, 4, 5
Dietary measures include moderate sodium restriction, avoidance of excessive fluid intake in severe heart failure, and avoidance of excessive alcohol consumption 3, 4, 5
Immunization with influenza and pneumococcal vaccines is recommended 2, 3

Avoid medications that can worsen heart failure, including most antiarrhythmic agents, most calcium channel blockers, and nonsteroidal anti-inflammatory drugs 2, 3
Monitor serum potassium carefully to prevent hypokalemia or hyperkalemia, and regularly assess symptoms, fluid status, and medication tolerance 2, 3, 4, 5