A 55-year-old man with HFrEF (EF 28%) is on maximally tolerated doses of carvedilol and sacubitril/valsartan. Potassium is 4.8 mEq/L and eGFR is 38 mL/min. Which additional therapy is recommended by ACC/AHA 2022 guidelines with proven mortality benefit in this population?
- A Spironolactone 25 mg/day
- B Digoxin 0.125 mg/day for additional neurohormonal blockade
- C Dapagliflozin (SGLT-2 inhibitor) ✓
- D Hydralazine-isosorbide dinitrate combination
Explanation
ACC/AHA 2022 HF guidelines give SGLT-2 inhibitors (dapagliflozin or empagliflozin) a Class I recommendation for HFrEF to reduce cardiovascular mortality and HF hospitalization (DAPA-HF and EMPEROR-Reduced trials). They are beneficial even in non-diabetic patients, safe with eGFR ≥20 mL/min, and do not worsen hyperkalaemia. Spironolactone is a strong option (RALES trial mortality benefit) but with eGFR 38 and K+ 4.8, there is significant hyperkalaemia risk. Digoxin reduces hospitalizations but not mortality. Hydralazine-nitrate is reserved for patients intolerant of ACEi/ARB or sacubitril/valsartan.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.