A 50-year-old woman has HFrEF (LVEF 28%) and is on maximally tolerated doses of sacubitril-valsartan, carvedilol, and spironolactone. Resting HR is 78 bpm in sinus rhythm. NT-proBNP remains elevated. What additional evidence-based therapy should be considered?
- A Add digoxin to reduce hospitalisation
- B Ivabradine, if resting HR ≥70 bpm on maximally tolerated beta blocker in sinus rhythm ✓
- C Increase spironolactone dose to 50 mg daily
- D Add hydralazine-nitrate combination as she is already on sacubitril/valsartan
Explanation
Ivabradine (If channel inhibitor, reduces heart rate without affecting contractility) is indicated in HFrEF patients in sinus rhythm with resting HR ≥70 bpm despite maximally tolerated beta blocker doses, per ESC/ACC guidelines (SHIFT trial). It reduces HF hospitalisation and CV death. This patient has HR 78 bpm despite carvedilol, making ivabradine an appropriate addition. Digoxin reduces HF hospitalisation but not mortality (DIG trial) and is a second-line add-on. Hydralazine-isosorbide dinitrate is used when ACEi/ARB/ARNI is not tolerated (per A-HeFT trial, predominantly in African-Americans), not as an add-on to sacubitril-valsartan. Spironolactone dose increase carries hyperkalaemia risk without evidence-based benefit beyond 25-50 mg.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.