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Heart failure with reduced ejection fraction — ABIM Board MCQ

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HardCardiovascularHeart failure with reduced ejection fractionABIM Board

A 57-year-old man is evaluated 6 months after an anterior myocardial infarction. He had been lost to follow-up and began lisinopril, metoprolol succinate, and furosemide 3 weeks ago after echocardiography showed a left ventricular ejection fraction of 28%. He is now euvolemic but continues to have dyspnea with ordinary activity. Blood pressure is 104/66 mm Hg, and pulse is 68/min. Echocardiography also shows moderate functional mitral regurgitation. Serum potassium is 4.4 mEq/L, and eGFR is 64 mL/min/1.73 m2. Which of the following additional management strategies is most appropriate now?

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

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Correct answer: D — Add spironolactone and an SGLT2 inhibitor

This patient has symptomatic HFrEF and remains short of complete disease-modifying therapy. His potassium and kidney function permit an MRA, and an SGLT2 inhibitor is indicated regardless of diabetes status. These agents have relatively modest blood-pressure effects, an advantage with his blood pressure of 104/66 mm Hg. Transition from lisinopril to sacubitril/valsartan should also be considered as tolerated. Hydralazine–isosorbide dinitrate should not replace tolerated renin-angiotensin system inhibition. Diltiazem is negatively inotropic and may worsen HFrEF. A primary-prevention ICD may become appropriate if the ejection fraction remains reduced after a sufficient course of optimized GDMT, but therapy was started only 3 weeks ago. Moderate secondary mitral regurgitation is initially treated by optimizing HFrEF therapy rather than isolated valve repair.

Reference: Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, Section 7.3.2: Pharmacological Treatment for HFrEF, 2022. https://professional.heart.org/-/media/832EA0F4E73948848612F228F7FA2D35.pdf