A 55-year-old man with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor and beta-blocker. He has persistent NYHA Class III symptoms, eGFR 55, K+ 4.2 mEq/L. Which additional drug improves mortality most significantly in this patient?

• A Mineralocorticoid receptor antagonist (spironolactone or eplerenone) ✓
• B Digoxin
• C Ivabradine if heart rate >70 bpm on beta-blocker
• D Hydralazine-nitrate combination

Explanation

The mineralocorticoid receptor antagonist (MRA) — spironolactone (RALES trial) or eplerenone (EMPHASIS-HF trial) — reduces all-cause mortality and hospitalisation by ~30% when added to ACE inhibitor + beta-blocker in HFrEF with NYHA II–IV symptoms. Key prerequisites include eGFR >30 and K+ <5.0 mEq/L. Digoxin reduces hospitalisations but has no mortality benefit. Ivabradine reduces heart rate but the mortality benefit is modest. Hydralazine-nitrate is reserved for ACE inhibitor/ARB intolerant 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.