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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 patient with HFrEF has LVEF 28% and takes sacubitril-valsartan, metoprolol succinate and spironolactone. They are euvolemic, eGFR is 60 mL/min/1.73 m2 and there is no prior ketoacidosis. Which additional therapy has outcome benefit?

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Correct answer: B — Add an SGLT2 inhibitor with routine monitoring

The best answer is “Add an SGLT2 inhibitor with routine monitoring”. In symptomatic HFrEF, SGLT2 inhibition is a foundational outcome-improving therapy regardless of diabetes, alongside ARNI, evidence-based beta blockade and mineralocorticoid-receptor antagonism. Digoxin can reduce selected symptoms but is not the fourth mortality-reducing pillar. Diltiazem and chronic prednisone are inappropriate, and sacubitril-valsartan should not be stopped for persistent reduced ejection fraction.

Reference: ACC/AHA/HFSA, Heart Failure Guideline: https://www.acc.org/Guidelines