Heart Failure: The Daily PANCE Blueprint
A 58-year-old man with heart failure and a reduced ejection fraction of 30% comes in for follow-up. He is not diabetic. Over the past few months you have him on sacubitril-valsartan, carvedilol, and spironolactone, all at target doses, and he feels better — but he still gets winded climbing a single flight of stairs (New York Heart Association class II). His blood pressure is 118/72, heart rate 68, potassium 4.4 mEq/L, and estimated GFR 68. Which of the following should you add next to further reduce his mortality and hospitalizations?
A. Increase the loop diuretic
B. Add an SGLT2 inhibitor (e.g., dapagliflozin)
C. Add digoxin
D. Add ivabradine
E. Add amlodipine
Answer and topic summary
The answer is B. Add an SGLT2 inhibitor (e.g., dapagliflozin).
Modern guideline-directed therapy for heart failure with reduced ejection fraction (HFrEF) is four pillars started early: an ARNI (sacubitril-valsartan, preferred over an ACE inhibitor/ARB), an evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and an SGLT2 inhibitor (dapagliflozin or empagliflozin). This patient is already on the first three, so the missing pillar is the SGLT2 inhibitor — and it lowers mortality and hospitalizations regardless of whether the patient has diabetes. A loop diuretic relieves congestion but has no mortality benefit; digoxin lowers hospitalizations with no mortality benefit; ivabradine is only for sinus rhythm with a heart rate ≥70 on a maximally tolerated beta-blocker; and a dihydropyridine like amlodipine treats blood pressure, not heart failure.
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