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Heart failure medication titration — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Heart failure medication titrationUSMLE Step 3

A 63-year-old with symptomatic HFrEF returns 2 weeks after lisinopril was replaced by sacubitril-valsartan after an appropriate washout. He also takes carvedilol, spironolactone, dapagliflozin, and furosemide. Blood pressure is 104/66 mm Hg without orthostasis, potassium is 4.9 mEq/L, creatinine rose from 1.0 to 1.2 mg/dL, congestion improved, and weight is stable. What is the best next step?

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Correct answer: C — Continue all four foundational classes with repeat laboratory and blood-pressure monitoring

The best answer is “Continue all four foundational classes with repeat laboratory and blood-pressure monitoring”. A modest creatinine increase with stable potassium, preserved perfusion, no orthostasis, and clinical improvement does not require withdrawal of foundational HFrEF therapy. ARNI, evidence-based beta blocker, MRA, and SGLT2 inhibitor should be continued with surveillance; each competing dose change may become appropriate with symptomatic hypotension, progressive kidney dysfunction, or clinically important hyperkalemia, none of which is present.

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