A 50-year-old man presents with progressive breathlessness. Echo shows EF 60%, concentric LVH, abnormal diastolic relaxation, enlarged left atrium (volume index 46 mL/m²), and elevated E/e' ratio of 17. BNP is 420 pg/mL. The diagnosis is HFpEF. The EMPEROR-Preserved and DELIVER trials demonstrated benefit of which class of drug in HFpEF?
- A Mineralocorticoid receptor antagonists (spironolactone) based on TOPCAT trial
- B SGLT2 inhibitors (empagliflozin or dapagliflozin) which reduced HF hospitalisation in HFpEF ✓
- C ARBs (irbesartan) based on I-PRESERVE trial showing mortality benefit
- D ACE inhibitors based on PEP-CHF trial showing survival benefit
Correct answer: B. SGLT2 inhibitors (empagliflozin or dapagliflozin) which reduced HF hospitalisation in HFpEF
Explanation
EMPEROR-Preserved (empagliflozin) and DELIVER (dapagliflozin) trials were the first large RCTs to demonstrate significant reduction in HF hospitalisation in HFpEF/HFmrEF. Both SGLT2 inhibitors are now guideline-recommended (Class IIa, ACC/AHA 2022) for HFpEF to reduce HF hospitalisations. The TOPCAT trial with spironolactone showed mixed results with regional variation. I-PRESERVE (irbesartan) and PEP-CHF (perindopril) showed no mortality benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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