A 62-year-old man with HFrEF (LVEF 32%) is already on maximally tolerated ACE inhibitor, beta-blocker, and aldosterone antagonist. He remains NYHA class III with eGFR 55 mL/min. Per 2022 AHA/ACC/HFSA Heart Failure guidelines, which agent should be added as the 4th pillar of GDMT (guideline-directed medical therapy)?

• A Hydralazine-nitrate combination
• B Digoxin to reduce hospitalization rate
• C SGLT2 inhibitor (dapagliflozin or empagliflozin) ✓
• D Ivabradine if resting HR >70 bpm

Explanation

SGLT2 inhibitors (dapagliflozin — DAPA-HF trial; empagliflozin — EMPEROR-Reduced trial) have been added as a 4th pillar of GDMT for HFrEF in the 2022 AHA/ACC/HFSA guidelines, alongside ACE inhibitor/ARB/ARNI, beta-blocker, and MRA. They reduce CV death and HF hospitalizations independent of diabetic status and renal function (down to eGFR ≥20 mL/min/1.73m² for dapagliflozin). Ivabradine (SHIFT trial) reduces HF hospitalization if HR >70 bpm on maximally-tolerated beta-blocker, but is not a core pillar. Hydralazine-nitrate is for ACEI/ARB-intolerant Black patients.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.