A 55-year-old man with ischemic cardiomyopathy and EF 28% is on optimal doses of carvedilol, lisinopril, and furosemide. Despite this, he remains NYHA class III with dyspnea on minimal exertion. Serum creatinine is 1.2 mg/dL, K⁺ 4.0 mEq/L, and eGFR 65 mL/min. Which additional drug has the strongest evidence for reducing mortality in this patient?

• A Digoxin 0.125 mg daily
• B Spironolactone (MRA) 25 mg daily ✓
• C Ivabradine if HR > 70/min
• D Metolazone 2.5 mg as needed

Explanation

The RALES and EMPHASIS-HF trials demonstrated that mineralocorticoid receptor antagonists (spironolactone, eplerenone) reduce all-cause mortality by approximately 30% in HFrEF patients who remain symptomatic (NYHA II–IV) despite ACE inhibitor and beta-blocker. In a patient with eGFR > 30 mL/min and K⁺ < 5.0 mEq/L, adding a MRA is a Class I indication. ARNI (sacubitril-valsartan) would also be appropriate as a step to replace ACEI, with even stronger mortality benefit per PARADIGM-HF.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.