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Heart failure titration — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Heart failure titrationUSMLE Step 3

A patient with ischemic cardiomyopathy has LVEF 30%, NYHA class II symptoms, sinus rhythm at 76/min, and blood pressure 104/66 mm Hg despite maximally tolerated carvedilol, sacubitril/valsartan, spironolactone, and an SGLT2 inhibitor. There has been no recent worsening-heart-failure event. Which add-on best targets the remaining guideline-defined physiologic criterion without materially lowering blood pressure?

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

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Correct answer: A — Ivabradine

The best answer is “Ivabradine”. The patient has stable symptomatic HFrEF, LVEF at most 35%, sinus rhythm, and resting heart rate at least 70 despite maximally tolerated beta blockade. Ivabradine selectively slows sinus rate with little blood-pressure effect. Vericiguat is considered after recent worsening HF, while digoxin lacks the same rhythm-and-rate eligibility criterion.

Reference: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: https://professional.heart.org/en/science-news/2022-guideline-for-the-management-of-heart-failure