Reduction of ICD indications after optimization of heart failure treatment in patients with severe left ventricular systolic dysfunction

Background: Patients with LVEF≤35% and NYHA class II or III heart failure under optimal medical treatment have an indication of an ICD in primary prevention. Data regarding the magnitude of improvement of LVEF after intensive optimization of heart failure medical treatment are scarce. Purpose: To assess the clinical, echocardiographic and biological impact of intensive optimization of heart failure medical treatment in patients with severe left ventricular systolic dysfunction. Methods: This is an observational prospective study in which patients visited in a heart failure unit with LVEF≤35%, without an ICD, with heart failure and non-optimal heart failure medical treatment are included. Up-titration of beta blockers, ACE inhibitors/ARB and aldosterone antagonist are gradually performed in the day hospital of the heart failure unit up to 100% of the target dose or the maximum tolerated dose. At 6 month after completion of drug up-titration the echocardiography is repeated and clinical follow-up assessed again. Results: 85 patients have been already included. 34/85 are still being up-titraded. 3/85 died during follow-up. The 6 month follow-up has been accomplished in 48/85 patients, age 65±14 years, 9 (19%) female, 20 (42%) with ischemic heart disease. Patients on 100% of target dose of beta blockers, ACE inhibitors/ARB and aldosterone antagonists increased from 8%, 23% and 17% to 81%, 77% and 72%, respectively, with up-titration. NYHA class diminished at 6 month: 2,1±0,6 vs 1,5±0,6, p 35% in 25/48 (52%) patients at 6 month after up-titration. Consequently, patients with an ICD indication were reduced: 44 (92%) vs 12 (25%) when comparing before and after 6 month of completion of optimization of heart failure medical therapy. Moreover, pro-BNP levels were also reduced: 2676±227 vs 1754±1804 pg/ml before and after 6 month of up-titration completion. Conclusions: Intensive optimization of heart failure medical therapy in patients with severe systolic left ventricular impairment improves symptoms and quality of life and reduces hospital admissions. Furthermore LVEF increases in the majority of patients and ICD indications are accordingly reduced.