A 60-year-old man with HFrEF (EF 28%) is on bisoprolol 10 mg, enalapril 10 mg BD, and spironolactone 25 mg. He remains NYHA Class III. eGFR is 55 mL/min/1.73 m². Which treatment addition has been shown to reduce ALL-CAUSE MORTALITY in this clinical scenario per the PARADIGM-HF trial?

• A Add ivabradine
• B Add empagliflozin
• C Add digoxin for rate control
• D Replace enalapril with sacubitril/valsartan (ARNI) ✓

Explanation

The PARADIGM-HF trial demonstrated that sacubitril/valsartan (ARNI) reduced all-cause mortality by 16% and CV death/HF hospitalisation by 20% compared to enalapril in HFrEF patients (EF ≤40%). Current ESC 2021 and ACC/AHA 2022 HF guidelines give sacubitril/valsartan a Class I recommendation as a replacement for ACE inhibitors in HFrEF. A 36-hour washout period from ACE inhibitor is required before starting ARNI to avoid angioedema. Empagliflozin also reduces mortality in HFrEF (EMPEROR-Reduced trial) and is now Class I, but PARADIGM-HF specifically demonstrated the ACE-i to ARNI switch benefit.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.