skip to main content

HFrEF — EECC MCQ

Instant feedback + full explanation. One question, done properly.

ModerateHeart FailureHFrEFEECC

A 62-year-old man with HFrEF (LVEF 25%) is on maximally tolerated doses of ramipril 10 mg, bisoprolol 10 mg, eplerenone 50 mg, and dapagliflozin 10 mg. His resting heart rate is 82 bpm in sinus rhythm. Blood pressure is 105/68 mmHg. He remains NYHA class II-III. What is the next most appropriate pharmacological step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Switch ramipril to sacubitril/valsartan AND add ivabradine

Explanation lettering: E = shown as B · B = shown as E

Per the 2021 ESC HF Guidelines, patients with HFrEF who remain symptomatic on ACEi should be switched to sacubitril/valsartan (recommended, based on PARADIGM-HF). Additionally, ivabradine is recommended in patients in sinus rhythm with resting heart rate 70 bpm or above despite maximally tolerated beta-blocker (Class IIa). This patient meets criteria for both interventions. Switching to ARNI alone (A) or adding ivabradine alone (B) each address only one issue. Digoxin (C) is considered only when the above options have been exhausted. Hydralazine/ISDN (D) is not preferred here.

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