What are the current guidelines for the pharmacological management of dilated cardiomyopathy in adults?

Pharmacological management of dilated cardiomyopathy (a common cause of heart failure with reduced ejection fraction) in adults involves the following steps:

• Review and stop any drugs that may cause or worsen heart failure.
• If symptoms of fluid overload are present, offer a loop diuretic (e.g., furosemide up to 80 mg daily) and titrate the dose according to symptoms.
• Offer an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker licensed for heart failure. Use clinical judgement to decide which to start first; for example, start with an ACE inhibitor if the patient has diabetes or fluid overload, as beta-blockers may initially worsen symptoms.
• If ACE inhibitors are not tolerated (commonly due to cough), offer an angiotensin-II receptor antagonist (AIIRA).
• If symptoms persist despite ACE inhibitor (or AIIRA) and beta-blocker therapy, add a mineralocorticoid receptor antagonist (MRA).
• If symptoms remain despite optimized standard care, seek specialist advice and consider additional options such as sacubitril valsartan (for ejection fraction <35%), SGLT-2 inhibitors (empagliflozin or dapagliflozin), ivabradine (for sinus rhythm with heart rate >75 bpm and EF <35%), hydralazine with nitrate (especially in African-Caribbean patients), or digoxin to improve symptoms.
• Monitor renal function, electrolytes, and blood pressure closely during titration of these medications.
• Consider antiplatelet therapy if atherosclerotic disease is present and statin therapy as indicated for cardiovascular risk management.

This pharmacological approach aims to improve symptoms, prevent worsening, and increase survival in adults with dilated cardiomyopathy presenting as heart failure with reduced ejection fraction.

Note: Initiation and titration of advanced therapies such as sacubitril valsartan and ivabradine should be done by or in consultation with a heart failure specialist team.

Ensure comorbidities and precipitating factors are optimally managed throughout treatment.

References: ¹,²