Question

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?

Accepted Answer

Start an SGLT2 inhibitor (e.g., dapagliflozin 10 mg daily)

Answer

Add hydralazine-isosorbide dinitrate

Answer

Increase spironolactone dose beyond guideline maximum

Answer

Start ivabradine

Answer

Refer for LVAD evaluation now

Practice question

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?