Management of Nonischemic Cardiomyopathy

Diagnostic Workup

The American College of Cardiology recommends obtaining cardiac MRI with late gadolinium enhancement and T2 mapping to characterize nonischemic cardiomyopathy, identify potential infiltrative diseases, detect myocardial fibrosis patterns, and assess for active myocardial inflammation 1, 3
Baseline laboratory assessment should include complete blood count, comprehensive metabolic panel, fasting glucose or HbA1c, lipid panel, thyroid-stimulating hormone, and BNP or NT-proBNP, as recommended by the American Heart Association 4, 3
A 12-lead ECG should be obtained to assess for conduction abnormalities, QRS duration, and arrhythmias, according to the European Society of Cardiology 4, 3

The American College of Cardiology recommends uptitrating ACE inhibitor (target lisinopril 20-40 mg daily) or switching to ARB if ACE inhibitor is not tolerated, as these reduce mortality by 10-40% in systolic heart failure 2, 3
Beta-blocker should be uptitrated to target dose (metoprolol succinate 200 mg daily, carvedilol 25 mg twice daily, or bisoprolol 10 mg daily) as these reduce mortality by 35% and sudden death by 40%, according to the American College of Cardiology 1, 2, 3
Mineralocorticoid receptor antagonist should be initiated if LVEF ≤35% or symptoms persist despite ACE inhibitor and beta-blocker therapy, as this improves survival and reduces morbidity, as recommended by the American College of Cardiology 1, 2, 3
SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) should be added regardless of diabetes status, as this reduces heart failure hospitalization and cardiovascular death, according to the European Society of Cardiology 5, 3

Cardiac resynchronization therapy should be considered if QRS duration ≥150 ms with LBBB pattern and LVEF ≤35% after GDMT optimization, as recommended by the American College of Cardiology 1, 3
ICD decision should be deferred until after 3 months of optimized medical therapy, as prophylactic ICD in nonischemic cardiomyopathy requires LVEF ≤35% despite optimal GDMT for ≥3 months, according to the American College of Cardiology 3

Electrolytes, creatinine, and BNP should be rechecked within 1-2 weeks after any medication changes, especially after initiating MRA, as recommended by the American College of Cardiology 2, 5
Follow-up should be scheduled within 2-4 weeks to assess medication tolerance and titration progress, according to the American College of Cardiology 5, 3

Patient should be taught about heart failure pathophysiology, symptom recognition, and when to seek urgent care, as recommended by the American Heart Association 3
Smoking cessation should be mandated if applicable, with nicotine replacement acceptable, according to the American College of Cardiology 3
Regular aerobic exercise should be recommended for stable NYHA Class II-III patients to prevent deconditioning and improve quality of life, as recommended by the American College of Cardiology 3