Heart failure with reduced ejection fraction — RACGP Fellowship MCQ

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ModerateChronic disease managementHeart failure with reduced ejection fractionRACGP Fellowship

A 70‑year‑old man has heart failure with reduced ejection fraction. He takes an ACE inhibitor and low‑dose β‑blocker. He remains breathless walking uphill. Blood pressure is 118/72 mmHg, potassium is 4.6 mmol/L and eGFR is 55 mL/min/1.73 m². What is the most appropriate management?

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Correct answer: D — Optimise guideline‑directed therapy by adding a mineralocorticoid receptor antagonist if tolerated

Answer D is correct. Australian guidance emphasises a ‘triple therapy’ backbone for HFrEF comprising a renin–angiotensin system antagonist, a β‑blocker and a mineralocorticoid receptor antagonist (MRA), which significantly reduces mortality and hospitalisations ([www1.racgp.org.au](https://www1.racgp.org.au/ajgp/2022/september/the-evolving-face-of-heart-failure-management?utm_source=openai)). This patient remains symptomatic on an ACE inhibitor and β‑blocker alone yet has stable blood pressure, renal function and potassium—making MRA initiation appropriate. Why the others are incorrect: A. Discontinuing β‑blocker undermines foundational mortality‑reducing therapy. C. Digoxin may alleviate symptoms but offers no mortality benefit and is considered only if symptoms persist after core therapies. B. NSAIDs worsen heart failure via sodium retention, renal compromise and interference with ACE inhibitor benefits. E. Stringent fluid restriction (500 mL/day) risks dehydration and renal injury and is generally not warranted in stable outpatients without volume overload.

Reference: The evolving face of heart failure management, AJGP (RACGP) 2022; NHFA‑CSANZ Guidelines 2018 (Australian). https://www1.racgp.org.au/ajgp/2022/september/the-evolving-face-of-heart-failure-management

Heart failure with reduced ejection fraction — RACGP Fellowship MCQ

A 70‑year‑old man has heart failure with reduced ejection fraction. He takes an ACE inhibitor and low‑dose β‑blocker. He remains breathless walking uphill. Blood pressure is 118/72 mmHg, potassium is 4.6 mmol/L and eGFR is 55 mL/min/1.73 m². What is the most appropriate management?