A 62-year-old man with hypertension and heart failure comes to the office for follow-up 2 weeks after hospital discharge for acute decompensated heart failure. The patient becomes short of breath after walking 1 block or climbing a flight of stairs but does not have orthopnea, cough, or hemoptysis. Current medications include metoprolol succinate, sacubitril-valsartan, furosemide, and spironolactone. Blood pressure is 128/76 mm Hg and pulse is 80/min. Oxygen saturation is 95% on room air. Jugular venous pressure is estimated at 8 cm H₂O. Lungs are clear to auscultation, and an S3 is heard at the apex. There is trace peripheral edema. Echocardiography shows left ventricular ejection fraction of 30%, mild mitral regurgitation, and mild pulmonary hypertension. The patient's serum creatinine is 1.2 mg/dL, and serum potassium is 5.0 mEq/L. Which of the following is the best additional therapy for this patient?

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Explanation: 11ec2b69_be21_f751_8f63_bffb6b8b622f_MD0005_00 This patient has symptomatic heart failure with echocardiography showing an ejection fraction of 30%, indicative of heart failure with reduced ejection fraction (HFrEF). HFrEF management focuses on symptom control (eg, diuresis), preservation of myocardial function, and reducing mortality. This patient is euvolemic and is on step 2 of optimal medical therapy for mortality reduction with an angiotensin receptor-neprilysin inhibitor (ARNI), a beta blocker, and an aldosterone antagonist. Based on current guidelines, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor (eg, dapagliflozin) is the next step in optimizing medical therapy. SGLT-2 inhibitors are primarily used in patients with diabetes mellitus type 2 to improve glycemic control, as inhibition of the sodium-glucose cotransporter in the proximal convoluted tubule promotes renal excretion of glucose. In addition to lowering serum glucose levels, this provides the additional benefit of osmotic diuresis and natriuresis, allowing symptomatic relief in patients with heart failure. SGLT-2 inhibitors have also demonstrated reduced mortality in patients with HFrEF, likely due to an incompletely understood mechanism affecting the myocardium directly. Therefore, SGLT-2 inhibitors are now recommended for patients with HFrEF (both with diabetes mellitus type 2 and without) and persistent symptoms (ie, New York Heart Association class II-IV) despite otherwise optimized medical therapy. class II-IV (Choice A) This patient is currently taking sacubitril-valsartan, a combination angiotensin receptor-neprilysin inhibitor (ARNI). Combining an ARNI with an additional angiotensin system blocker (eg, ACE inhibitor, angiotensin receptor blocker alone) has minimal added benefit and is generally contraindicated due to increased risk of adverse effects (eg, hyperkalemia, bradykinin-induced angioedema). (Choice B) Dihydropyridine calcium channel blockers (eg, amlodipine, felodipine) do not provide any symptomatic or mortality benefit in HFrEF and have no direct role in management. (Choices C and D) Endothelin receptor antagonists (eg, bosentan) and phosphodiesterase-5 inhibitors (eg, sildenafil) improve pulmonary hemodynamics and exercise capacity in patients with group 1 pulmonary hypertension (eg, idiopathic pulmonary arterial hypertension). However, these drugs have not shown benefit for pulmonary hypertension due to left-sided heart disease (ie, group 2 pulmonary hypertension). Educational objective: Sodium-glucose cotransporter-2 (SGLT-2) inhibitors (eg, dapagliflozin) have been shown to reduce mortality in patients with heart failure with reduced ejection fraction (HFrEF) both with diabetes mellitus type 2 and without. Therefore, they are recommended in patients with HFrEF and persistent symptoms despite otherwise optimized medical therapy. References: 2021 update to the 2017 acc expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American college of cardiology solution set oversight committee. (http://www.ncbi.nlm.nih.gov/pubmed/33446410) Dapagliflozin in patients with heart failure and reduced ejection fraction. (http://www.ncbi.nlm.nih.gov/pubmed/31535829)

A 62-Year-Old Man with Hypertension and Heart Failure Comes to the Office