A 62-year-old woman with HFrEF (EF 32%) is on maximally tolerated ACE inhibitor, beta-blocker, and spironolactone. Her NYHA class remains III despite 6 months of optimal medical therapy. Her BP is 92/60 mmHg and HR 72 bpm. What additional therapy should be considered to improve mortality based on PARADIGM-HF trial evidence?
- A Replace ACE inhibitor with sacubitril-valsartan (ARNI) — the PARADIGM-HF trial showed 20% relative risk reduction in CV death and HF hospitalisation ✓
- B Add hydralazine-nitrate combination (ISDN-H) for additional vasodilation
- C Add ivabradine since HR is 72 and EF < 35%
- D Add digoxin for rate control and symptom relief
Correct answer: A. Replace ACE inhibitor with sacubitril-valsartan (ARNI) — the PARADIGM-HF trial showed 20% relative risk reduction in CV death and HF hospitalisation
Explanation
The PARADIGM-HF trial demonstrated a 20% relative risk reduction in the composite of CV death and HF hospitalisation when sacubitril-valsartan replaced enalapril in HFrEF patients. Sacubitril-valsartan (ARNI) is now Class I recommended by ESC/AHA for HFrEF to replace RAAS inhibition. The ACE inhibitor must be stopped 36 hours before starting sacubitril-valsartan to avoid angioedema. Ivabradine is indicated when HR ≥ 70–75 bpm on maximally tolerated beta-blocker.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.