A 52-year-old man with HFrEF (LVEF 30%) is on maximally tolerated beta-blocker, ACE inhibitor, and mineralocorticoid receptor antagonist. He remains in NYHA class III. eGFR is 55, potassium 4.2 mEq/L. What is the next evidence-based therapy to add?
- A Ivabradine if heart rate > 70 bpm on maximally tolerated beta-blocker
- B Dapagliflozin (SGLT2 inhibitor) ✓
- C Digoxin to improve symptoms
- D Hydralazine + isosorbide dinitrate
Explanation
SGLT2 inhibitors (dapagliflozin — DAPA-HF; empagliflozin — EMPEROR-Reduced) are now Class I recommendations in HFrEF for reducing cardiovascular death and worsening heart failure, added to the existing 'three pillars' (ACE inhibitor/ARNi, beta-blocker, MRA). They form the fourth pillar of guideline-directed medical therapy per ESC 2021 and AHA 2022 HF guidelines. Ivabradine is indicated (Class IIa) if HR remains ≥ 70 bpm in sinus rhythm after maximum beta-blocker, but SGLT2i has stronger Class I evidence. Digoxin reduces hospitalisations but does not reduce mortality. Hydralazine-ISDN is an alternative vasodilator for ACE inhibitor/ARB-intolerant patients.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.