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Heart failure with reduced ejection fraction — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Heart failure with reduced ejection fractionUSMLE Step 3

A 58-year-old self-identified Black man has NYHA class III HFrEF with an ejection fraction of 28% despite maximally tolerated sacubitril-valsartan, carvedilol, spironolactone, and dapagliflozin. He is in sinus rhythm at 68/min, QRS duration is 100 ms, and he has had no recent worsening-heart-failure admission. Which additional therapy is specifically recommended to reduce morbidity and mortality in this setting?

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Correct answer: E — Add fixed-dose hydralazine plus isosorbide dinitrate to the foundational regimen

The best answer is “Add fixed-dose hydralazine plus isosorbide dinitrate to the foundational regimen”. For self-identified Black patients with NYHA class III–IV HFrEF already receiving optimal foundational therapy, fixed-dose hydralazine plus isosorbide dinitrate is recommended to improve outcomes. Ivabradine requires sinus rhythm with a resting rate at least 70/min, vericiguat is considered after recent worsening heart failure, and a narrow QRS does not support resynchronization.

Reference: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: https://professional.heart.org/-/media/832EA0F4E73948848612F228F7FA2D35.pdf