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Heart Failure (HFrEF) — EECC MCQ

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MediumCardiologyHeart Failure (HFrEF)EECC

A 64-year-old with HFrEF (EF 30%) on maximally tolerated sacubitril/valsartan, metoprolol succinate, and spironolactone has NYHA II symptoms, eGFR 58 mL/min/1.73 m², K⁺ 4.6 mEq/L. Next best disease-modifying therapy?

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Correct answer: D — Start an SGLT2 inhibitor (e.g., dapagliflozin 10 mg daily)

SGLT2 inhibitors reduce CV death and HF hospitalizations in HFrEF regardless of diabetes and are part of guideline-directed quadruple therapy. Hydralazine-isosorbide (A) is on specialist advice when standard renin–angiotensin system treatment is unsuitable. Increasing MRA above targets (B) is nonstandard. Ivabradine (C) is for sinus rhythm, HR ≥70 on max beta-blocker; disease-modifying but added after SGLT2. LVAD (E) is for advanced, refractory HF.

Reference: NICE NG106: Chronic heart failure in adults—diagnosis and management: https://www.nice.org.uk/guidance/ng106/chapter/recommendations