A 57-year-old man comes to the office after a recent hospitalization. Two weeks ago, he went to the emergency department due to chest pressure and was diagnosed with an acute ST elevation myocardial infarction. Emergency coronary angiography revealed an occluded left anterior descending artery, which was opened with a stent. The patient did well after the procedure and remained in the hospital for 2 days. Since leaving the hospital, he has had no further chest discomfort. The patient notes dyspnea on exertion, and his current exercise tolerance is limited to walking 2 blocks on a flat surface. Other medical issues include hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include carvedilol, sacubitril-valsartan, aspirin, ticagrelor, atorvastatin, dapagliflozin, and furosemide. Temperature is 36.7 C (98 F), blood pressure is 125/70 mm Hg, and pulse is 88/min. BMI is 33 kg/m². The patient is in no acute distress. Estimated jugular venous pressure is 12 cm H₂O. There is a 2/6 holosystolic apical murmur that radiates to the axilla. Crackles are heard at the right lung base that clear with deep inspiration. There is 1+ pitting lower extremity edema bilaterally to the mid-shin. Laboratory results are as follows: ECG shows normal sinus rhythm. There are Q waves in the anterior precordial leads with a QRS complex duration of 80 msec. Echocardiography performed prior to discharge showed hypokinesis of the anterior and anterolateral walls, moderate mitral regurgitation, and a left ventricular ejection fraction of 30%. Which of the following would be the most appropriate next step in the management of this patient?

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11ec193a_973c_94a7_853d_73930871917c_MD0002_00 This patient has severe left ventricular systolic dysfunction after an ST elevation myocardial infarction (MI); the addition of an aldosterone antagonist (eg, spironolactone, eplerenone) to therapy with a beta blocker and angiotensin system blocker (eg, angiotensin blocker-neprilysin inhibitor, ACE inhibitor, angiotensin receptor blocker) improves both morbidity and mortality in these patients. A portion of the benefit of aldosterone antagonists is likely due to inhibition of aldosterone-driven cardiac remodeling. In addition, their potassium-sparing effect counteracts the potassium-wasting of loop (eg, furosemide) and thiazide (eg, metolazone) diuretics, and lowers the risk of hypokalemia-induced arrhythmia. Aldosterone antagonists should be avoided in patients with significant renal disease (creatinine clearance <30 mL/min) or hyperkalemia (serum potassium >5 mEq/L), and patients receiving these drugs should undergo serial monitoring of serum potassium and renal function. (Choice A) Amlodipine does not improve symptoms or survival in patients with heart failure, but it can be used to treat hypertension or stable angina (which are not present in this patient). Other calcium channel blockers (eg, nifedipine, diltiazem) are associated with worsening heart failure and should be avoided. (Choice C) Hydralazine (in combination with a long-acting nitrate) is usually indicated for patients with heart failure who are unable to tolerate angiotensin system blockers or have persistent symptoms despite the addition of an aldosterone antagonist. (Choice D) An implantable cardioverter-defibrillator can lower the risk of sudden cardiac death in patients with substantially reduced left ventricular ejection fraction. However, current guidelines recommend that these devices not be placed until 40 days after MI or 3 months after revascularization on optimal medical therapy. An implantable cardioverter-defibrillator (Choice E) Mitral valve repair is most commonly indicated for patients with severe primary mitral regurgitation (MR). This patient likely has secondary mitral regurgitation from post-MI ventricular dilation, which may gradually improve with medical therapy. Transcatheter mitral valve clip repair may be appropriate for some patients with moderate to severe secondary MR, but it should only be considered following a trial of optimized medical therapy. Educational objective: The addition of an aldosterone antagonist (eg, spironolactone, eplerenone) is indicated in patients who are post-ST elevation myocardial infarction with left ventricular ejection fraction ≤40% and symptomatic heart failure or diabetes mellitus, and those with New York Heart Association functional class II to IV heart failure and left ventricular ejection fraction ≤35%. __________ References: Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/12668699) 2017 ACC/AHA/HFSA Focused Updated of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/28455343)

A 57-Year-Old Man Comes to the Office After a Recent