This patient with heart failure and a low left ventricular ejection fraction should be referred for placement of an implantable cardioverter-defibrillator (ICD). For patients with an ejection fraction less than or equal to 35% and New York Heart Association (NYHA) functional class II or III heart failure on optimal medical therapy, placement of an ICD is a class I indication. Patients with new-onset heart failure should not undergo placement of an ICD because ventricular function often recovers to above 35%. This patient, however, is on appropriate medical therapy, has had heart failure for at least 6 months, and is still symptomatic. For patients with NYHA functional class IV heart failure symptoms, an ICD is not warranted unless the patient is a cardiac transplant candidate.
Cardiac resynchronization therapy (CRT) with a biventricular pacemaker to improve hemodynamic function of the heart may also be considered in patients with persistent heart failure but is reserved for patients with evidence of conduction system disease. The 2013 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS) guideline recommends CRT in patients with an ejection fraction of 35% or below, NYHA functional class III to IV symptoms on guideline-directed medical therapy, and left bundle branch block with QRS duration greater than or equal to 150 ms. With a QRS width of 100 ms, this patient is not a candidate for a biventricular pacemaker in addition to an ICD.
Adding an angiotensin receptor blocker to a heart failure regimen that already includes an ACE inhibitor would not be indicated in this patient as it would not provide additional benefit, and this medication combination has been shown to increase risk of hyperkalemia and kidney injury.
Because this patient's heart rate is 56/min, indicating adequate β-blockade, and his blood pressure is at a desired level, no benefit would be expected by increasing his dose of carvedilol.
Indications for mitral valve replacement, an invasive procedure that carries risks, include the presence of severe mitral regurgitation and NYHA class III or IV symptoms attributed to the valve disease. None of these are present in this patient. This patient's mitral regurgitation is “functional,” meaning it is more likely to be a result of his dilated cardiomyopathy and not the underlying cause.