Acute Decompensated Heart Failure — EECC MCQ

Correct answer: E — Initiate low-dose SGLT2 inhibitor and beta-blocker once stabilised, with early up-titration and introduction of remaining agents before discharge

This patient has acute decompensated HFrEF with pulmonary oedema, but no cardiogenic shock: he is warm peripherally, lactate is normal and he is not requiring inotropes or vasopressors. The priority is IV loop diuresis and clinical stabilisation. Disease-modifying HFrEF therapy should not be deferred to a 6-week outpatient review, because initiation during the index admission improves uptake and is expected in UK practice. However, it should also not be started as all four drugs simultaneously while he is still acutely congested and hypotensive. Once stabilised, low-dose guideline-directed therapy should be introduced in hospital, with monitoring of blood pressure, renal function, potassium and clinical status. In particular, beta-blockers are started or restarted during admission once acute HF has stabilised; SGLT2 inhibitors have minimal blood-pressure effect and are part of current HFrEF therapy. The remaining pillars — ACE inhibitor/ARB/ARNI as appropriate and MRA — should be introduced early if tolerated, ideally before discharge, rather than left entirely to outpatient sequential initiation. Therefore the best answer is E.

Reference: NICE. Chronic heart failure in adults: diagnosis and management, NG106, updated 2025; and NICE. Acute heart failure: diagnosis and management, CG187. https://www.nice.org.uk/guidance/ng106 and https://www.nice.org.uk/guidance/cg187