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SGLT2i in HFrEF — RACP Adult Medicine MCQ

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HardCardiologySGLT2i in HFrEFRACP Adult Medicine

A 55-year-old with HFrEF, LVEF 30%, remains NYHA II despite tolerated ramipril, bisoprolol and spironolactone. He is in sinus rhythm at 65/min, BP is 100/66 mmHg, eGFR 55 mL/min/1.73 m² and potassium 4.5 mmol/L. Which addition completes a currently recommended foundational drug class with little dependence on heart rate?

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

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Correct answer: B — Add dapagliflozin after counselling about volume status, genital infection and sick-day interruption

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

E is correct. An SGLT2 inhibitor is one of the four foundational HFrEF drug classes and improves heart-failure outcomes irrespective of diabetes; the heart rate does not limit its use, although volume status, renal function and temporary interruption during acute illness or fasting require attention. A is inappropriate at a resting sinus rate of 65/min and does not replace missing foundational therapy. B may reduce selected admissions but is not a superior mortality-modifying pillar. C is negatively inotropic in HFrEF. D can worsen fluid retention and heart failure. Replacement of the ACE inhibitor by sacubitril–valsartan may also be considered, but the question specifically identifies the entirely absent class in a patient with borderline pressure.

Reference: Heart Foundation: Heart failure clinical guidelines: https://www.heartfoundation.org.au/for-professionals/heart-failure-clinical-guidelines