A 58-year-old man with heart failure with reduced EF (HFrEF; LVEF 28%) is optimised on carvedilol 25 mg BD, sacubitril-valsartan 97/103 mg BD, and spironolactone 50 mg. NYHA class II. NT-proBNP is 1200 pg/mL. Per ESC 2021 and AHA 2022 HF guidelines, which fourth foundational therapy should now be added?
- A An SGLT-2 inhibitor (dapagliflozin or empagliflozin) — Class I recommendation for all HFrEF regardless of diabetes status ✓
- B Ivabradine — reduces heart rate below 70 bpm in sinus rhythm reducing mortality
- C Digoxin — to reduce hospitalisation in refractory HFrEF on guideline-directed therapy
- D Hydralazine-isosorbide dinitrate — recommended for all HFrEF not tolerating RAAS inhibitors
Explanation
Following DAPA-HF (dapagliflozin, NEJM 2019) and EMPEROR-Reduced (empagliflozin, NEJM 2020) trials, SGLT-2 inhibitors were incorporated into both ESC 2021 and ACC/AHA 2022 guidelines as Class IA recommendations for all HFrEF patients to reduce cardiovascular death and HF hospitalisation, irrespective of diabetes status. The four pillars of HFrEF therapy are now: ACE-I/ARB-neprilysin inhibitor (ARNI), beta-blocker, MRA (mineralocorticoid receptor antagonist), and SGLT-2 inhibitor. Ivabradine is a fifth-line additive therapy for HR > 70 bpm on maximally tolerated beta-blocker.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.