A 72-year-old man comes to the office 4 weeks following discharge from the hospital due to an episode of acute decompensated heart failure. The patient feels much better now but claims that he gets tired easily. He becomes short of breath after walking a few blocks on a level surface. He has a history of myocardial infarction, coronary artery bypass grafting, ischemic cardiomyopathy, hypertension, hyperlipidemia, and type 2 diabetes mellitus. The patient has had several hospital admissions for decompensated heart failure over the past 2 years. His home medications include aspirin, carvedilol, sacubitril-valsartan, atorvastatin, furosemide, and insulin. Temperature is 37.2 C (99 F), blood pressure is 128/76 mm Hg, pulse is 76/min, and respirations are 16/min. Pulse oximetry is 94% on room air. The patient is in no apparent respiratory distress. Jugular venous pressure is measured at 8 cm H₂O. Lung examination reveals clear lung fields with decreased breath sounds at the bases. Cardiac examination reveals normal S1 and S2 along with a 2/6 holosystolic murmur heard over the cardiac apex. There is minimal pitting edema around the ankles. Laboratory results are as follows: ECG is shown in the exhibit. A recent echocardiogram showed a mildly dilated left ventricular cavity with akinesis of the anterior and anteroseptal walls as well as a left ventricular ejection fraction of 30%. Which of the following additional treatments would most benefit this patient?

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11ec193a_9742_12ee_853d_0b4aa11313e7_MD0002_00 This patient has heart failure with reduced ejection fraction (HFrEF) and New York Heart Association (NYHA) class II symptoms at baseline. The addition of an aldosterone antagonist (eg, spironolactone, eplerenone) to beta blocker and angiotensin system blocker (eg, ACE inhibitor, angiotensin receptor blocker, or angiotensin receptor neprilysin inhibitor) therapy has been shown to reduce morbidity and mortality in symptomatic patients (ie, NYHA class II, III, or IV) with left ventricular ejection fraction (LVEF) ?35%. New York Heart Association (NYHA) class II Aldosterone antagonists should be avoided in patients with significant renal disease (creatinine clearance <30 mL/min) or hyperkalemia (serum potassium >5 mEq/L). Patients receiving aldosterone antagonists should undergo serial monitoring of serum potassium and renal function. (Choice A) Cardiac resynchronization therapy with biventricular pacing is recommended in patients with LVEF ?35%, a left bundle branch block with QRS duration ?150 msec, and persistent symptoms despite optimal medical therapy. It is not indicated in this patient with ECG showing a narrow QRS complex (ie, duration <120 msec). (Choice B) Digoxin is used as an adjunctive therapy in patients with HFrEF who continue to have symptoms despite optimal medical therapy with a beta blocker, angiotensin system blocker, aldosterone antagonist, and diuretics. Digoxin reduces the rate of hospitalization in these patients, but it has not been shown to improve overall survival. (Choice C) The addition of hydralazine alone has demonstrated no significant benefit in the management of HFrEF; however, hydralazine combined with a long-acting nitrate (eg, isosorbide dinitrate) has demonstrated reduced morbidity and mortality. This therapy is typically reserved for patients with persistent symptoms despite the addition of an aldosterone antagonist or patients who are intolerant of angiotensin system blockers. (Choice D) Metolazone is a thiazide diuretic that is usually given to patients with volume overload that is refractory to loop diuretics (eg, furosemide). This patient does not have evidence of significant volume overload (ie, jugular venous pressure is normal and there is minimal peripheral edema), and likely would not benefit from metolazone. Educational objective: The addition of an aldosterone antagonist (eg, spironolactone, eplerenone) to beta blocker and angiotensin system blocker therapy reduces morbidity and mortality in patients with symptomatic heart failure (ie, New York Heart Association class II, III, or IV) and left ventricular ejection fraction ?35%. __________ References: Eplerenone in patients with systolic heart failure and mild symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/21073363) The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. (http://www.ncbi.nlm.nih.gov/pubmed/10471456) 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/23741058)

A 72-Year-Old Man Comes to the Office 4 Weeks Following