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Left ventricular systolic dysfunction — Clinical Guidelines

Overview

Left ventricular systolic dysfunction (LVSD) refers to a condition characterized by reduced ejection fraction and impaired systolic function of the left ventricle, often seen in heart failure and post-myocardial infarction settings 1 7.

Diagnosis

Echocardiography: Essential for assessing left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) for risk stratification 1 3.

Strain Analysis: Utilize myocardial deformation imaging, including global longitudinal strain (GLS) and mechanical dispersion (MD), to refine prognosis 1.

Renal Function Monitoring: Regular assessment of renal function, especially when initiating RAAS inhibitors, to detect worsening renal function (WRF) 2.

Thyroid Function Tests: Evaluate thyroid hormone levels, particularly T3 levels, in patients on amiodarone therapy 4.

Electrocardiography: Monitor for signs of arrhythmias and assess for the presence of mitral and tricuspid regurgitation 7.

Management

RAAS Inhibitors: Initiate renin-angiotensin-aldosterone system inhibitors to reduce mortality, despite potential WRF 2.

Amiodarone Therapy: Consider with caution, monitoring thyroid function due to potential LOWT3 syndrome impacting prognosis 4.

BNP Monitoring: Utilize brain natriuretic peptide (BNP) levels for risk stratification, leveraging its stability in whole blood for clinical convenience 8.

Symptom Management: Use diuretics, ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists as per standard heart failure guidelines 1 2.

Exercise Testing: Employ 6-minute walk test to estimate functional capacity and predict peak oxygen uptake in patients unable to undergo maximal exercise testing 6.

Special Populations

Elderly: Monitor closely for renal function changes when using RAAS inhibitors and consider thyroid function in those on amiodarone 2 4.

Comorbidities: Higher grades of mitral regurgitation (MR) and tricuspid regurgitation (TR) correlate with worse outcomes; manage these conditions aggressively 7.

Key Recommendations

Utilize myocardial deformation parameters like GLS and MD from echocardiography for risk stratification in LVSD patients (Evidence: Moderate) 1.

Initiate RAAS inhibitors for LVSD patients despite potential worsening renal function, as they reduce overall mortality (Evidence: Strong) 2.

Regularly assess thyroid function, particularly T3 levels, in patients with LVSD on amiodarone therapy to guide prognosis (Evidence: Moderate) 4.

Consider BNP levels measured in whole blood as a stable and practical biomarker for risk stratification in LVSD (Evidence: Moderate) 8.

Use the 6-minute walk test as a surrogate for peak oxygen uptake in assessing functional capacity in male LVSD patients (Evidence: Moderate) 6.

References

1 Perry R, Patil S, Marx C, Horsfall M, Chew DP, Sree Raman K et al.. Advanced Echocardiographic Imaging for Prediction of SCD in Moderate and Severe LV Systolic Function. JACC. Cardiovascular imaging 2020. link 2 Clark H, Krum H, Hopper I. Worsening renal function during renin-angiotensin-aldosterone system inhibitor initiation and long-term outcomes in patients with left ventricular systolic dysfunction. European journal of heart failure 2014. link 3 Stoebe S, Tarr A, Pfeiffer D, Hagendorff A. The impact of the width of the tracking area on speckle tracking parameters-methodological aspects of deformation imaging. Echocardiography (Mount Kisco, N.Y.) 2014. link 4 Coceani M, Molinaro S, Scalese M, Landi P, Carpeggiani C, L'abbate A et al.. Thyroid hormone, amiodarone therapy, and prognosis in left ventricular systolic dysfunction. Journal of endocrinological investigation 2011. link 5 de Sousa MR, Barbosa MP, Lombardi F, Ribeiro AL. Standard Deviation of normal interbeat intervals as a risk marker in patients with left ventricular systolic dysfunction: a meta-analysis. International journal of cardiology 2010. link 6 Ingle L, Goode K, Rigby AS, Cleland JG, Clark AL. Predicting peak oxygen uptake from 6-min walk test performance in male patients with left ventricular systolic dysfunction. European journal of heart failure 2006. link 7 Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. American heart journal 2002. link 8 Murdoch DR, Byrne J, Morton JJ, McDonagh TA, Robb SD, Clements S et al.. Brain natriuretic peptide is stable in whole blood and can be measured using a simple rapid assay: implications for clinical practice. Heart (British Cardiac Society) 1997. link 9 Mori M, Takeuchi M, Takaoka H, Hata K, Hayashi Y, Yokoyama M. Effect of NKH477, a new water-soluble forskolin derivative, on arterial-ventricular coupling and mechanical energy transduction in patients with left ventricular systolic dysfunction: comparison with dobutamine. Journal of cardiovascular pharmacology 1994. link

Left ventricular systolic dysfunction