A 66-year-old woman comes to the office to follow up for heart failure. Four weeks ago, she was diagnosed with new onset heart failure with reduced ejection fraction of 30%. At that time, ECG showed normal sinus rhythm, narrow QRS complexes, and T-wave inversion in the lateral leads. Coronary angiogram revealed no significant coronary artery disease. She is feeling better except for mild exertional fatigue. The patient typically uses 2 pillows to sleep and gets up once at night to urinate. She has no lightheadedness. Her only other medical condition is type 2 diabetes mellitus. Current medical therapy is sacubitril-valsartan, metoprolol succinate, and furosemide. Blood pressure is 109/60 mm Hg, pulse is 62/min, and respirations are 12/min. Pulse oximetry shows 98% on room air. Examination shows normal jugular venous pressure, clear lungs, and a 2/6 pansystolic murmur at the apex. The abdomen is soft and nontender. She has no peripheral edema. Laboratory results are as follows: Which of the following is the most appropriate next step in pharmacotherapy management of this patient?

Question

A 66-year-old woman comes to the office to follow up for heart failure.  Four weeks ago, she was diagnosed with new onset heart failure with reduced ejection fraction of 30%.  At that time, ECG showed normal sinus rhythm, narrow QRS complexes, and T-wave inversion in the lateral leads.  Coronary angiogram revealed no significant coronary artery disease.  She is feeling better except for mild exertional fatigue.  The patient typically uses 2 pillows to sleep and gets up once at night to urinate.  She has no lightheadedness.  Her only other medical condition is type 2 diabetes mellitus.  Current medical therapy is sacubitril-valsartan, metoprolol succinate, and furosemide.  Blood pressure is 109/60 mm Hg, pulse is 62/min, and respirations are 12/min.  Pulse oximetry shows 98% on room air.  Examination shows normal jugular venous pressure, clear lungs, and a 2/6 pansystolic murmur at the apex.  The abdomen is soft and nontender.  She has no peripheral edema.  Laboratory results are as follows:  Which of the following is the most appropriate next step in pharmacotherapy management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be25_2ba5_8f63_61ba03fbea8f_MD0005_00 This patient with heart failure with reduced ejection fraction (HFrEF) is currently managed on initial optimized medical therapy with an angiotensin system inhibitor (eg, sacubitril-valsartan), a beta blocker (eg, metoprolol succinate), and a loop diuretic (eg, furosemide). She has persistent New York Heart Association (NYHA) class II symptoms and a recent echocardiogram showing left ventricular ejection fraction (LVEF) of 30%; therefore, an aldosterone antagonist (eg, spironolactone, eplerenone) should be added to her medication regimen. class II Aldosterone antagonists improve mortality and reduce heart failure-related hospitalization, and are therefore indicated in the following patient populations: NYHA class II, III, or IV heart failure (essentially any symptoms) and LVEF ≤35% ST elevation myocardial infarction complicated by LVEF ≤40% and either heart failure symptoms or comorbid diabetes mellitus Due to the risk of hyperkalemia, aldosterone antagonists should be avoided in patients with underlying hyperkalemia (serum potassium >5 mEq/L) or advanced renal failure (creatinine clearance <30 mL/min). In addition, spironolactone, but not eplerenone, is associated with endocrine side effects (eg, gynecomastia, decreased libido) that are sometimes use-limiting. (Choice B) ACE inhibitors (eg, lisinopril) improve survival in patients with symptomatic HFrEF (LVEF ≤40%), but to a slightly lesser extent than angiotensin receptor-neprilysin inhibitors (eg, sacubitril-valsartan). The addition of an ACE inhibitor to an angiotensin receptor-neprilysin inhibitor is not recommended due to minimal incremental benefit and increased risk of adverse effects (eg, hyperkalemia, angioedema). (Choices C and E) Metolazone is a thiazide diuretic that can be added to loop diuretic therapy in patients with volume overload that is refractory to loop diuretics alone. This patient has no evidence of volume overload (eg, jugular venous distension, pulmonary crackles, lower extremity edema) and the addition of metolazone is not indicated. Discontinuing furosemide is also not appropriate as some diuretic usage is usually needed to maintain euvolemia in HFrEF. This patient's renal function is normal; therefore, there is no indication to discontinue furosemide. (Choice D) Providing the maximum tolerated dose of beta blocker is beneficial in the treatment of HFrEF. This patient is tolerating high doses of metoprolol without hypotension, bradycardia, or other adverse effects; therefore, decreasing the dose is not indicated. Educational objective: The addition of an aldosterone antagonist (eg, spironolactone, eplerenone) to initial optimized medical therapy is indicated in patients with persistent symptomatic heart failure and left ventricular ejection fraction ≤35%. These drugs improve mortality and reduce heart failure hospitalization in this population. References: Eplerenone in patients with systolic heart failure and mild symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/21073363) 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)

A 66-Year-Old Woman Comes to the Office to Follow Up