A 58-year-old man has HFrEF (LVEF 28%, NYHA Class III) on maximally tolerated ACE inhibitor and carvedilol. His eGFR is 48 mL/min, K+ 4.5 mEq/L, and there are no recent hospitalizations. According to the DAPA-HF and EMPEROR-Reduced trial evidence (AHA/ACC 2022 heart failure guidelines), the addition of which drug is now considered a fourth pillar of HFrEF therapy?
- A Digoxin for symptom control and hospitalization reduction
- B Dapagliflozin or empagliflozin (SGLT2 inhibitor) ✓
- C Ivabradine for heart rate reduction
- D Diuretics (furosemide) as the fourth pillar
Explanation
The four pillars of HFrEF therapy per AHA/ACC 2022 guidelines are: (1) ACE inhibitor/ARB/ARNI (sacubitril-valsartan), (2) Beta-blocker (carvedilol, metoprolol succinate, bisoprolol), (3) Mineralocorticoid receptor antagonist (spironolactone/eplerenone), and (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). The DAPA-HF trial (dapagliflozin) and EMPEROR-Reduced trial (empagliflozin) both showed significant reduction in cardiovascular death and worsening HF hospitalization, regardless of diabetes status. SGLT2i are safe in eGFR ≥20 for HF benefit. Digoxin is Class IIb for symptom control; ivabradine is Class IIa for HR ≥70 on max beta-blocker; diuretics are for symptom control, not mortality modification.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.