A 55-year-old man with HFrEF (LVEF 28%) is on maximally tolerated carvedilol, sacubitril/valsartan, and spironolactone. His resting heart rate is 78 bpm in sinus rhythm despite maximal beta-blocker. His NYHA class remains III. Which additional therapy has an indication-specific mortality benefit in this setting?

• A Digoxin
• B Ivabradine (SHIFT trial) ✓
• C Amiodarone
• D Hydralazine plus isosorbide dinitrate

Explanation

Ivabradine selectively inhibits the I(f) current (funny current) in the sinoatrial node, reducing heart rate in sinus rhythm without negative inotropy. The SHIFT trial demonstrated a significant reduction in cardiovascular death and HF hospitalisation in patients with HFrEF (LVEF ≤35%), sinus rhythm, and resting heart rate ≥70 bpm despite maximally tolerated beta-blocker. Resting HR 78 bpm in this patient meets the threshold. Hydralazine/ISDN is an alternative to RAAS blockade in patients intolerant of ACE inhibitor/ARB/ARNI (A-HeFT trial, primarily in Black patients). Digoxin reduces hospitalisation but has no mortality 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.