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Difficulty: HardPharmacologic Interventions

During a post-discharge follow-up visit, a physician evaluates a 6565-year-old male who was hospitalized three weeks ago for an anterior ST-elevation myocardial infarction complicated by acute decompensated heart failure. He currently performs activities of daily living independently but notes mild shortness of breath when walking up a slight incline. His medical history includes hypertension, type 2 diabetes mellitus, and a severe episode of oropharyngeal swelling that required emergency intubation shortly after initiating lisinopril three years ago.

Current medications include aspirin, clopidogrel, atorvastatin, and furosemide as needed.

Vital signs show a blood pressure of 122/78122/78 mmHg, a heart rate of 7070/min, and a respiratory rate of 1616/min. Physical examination reveals no jugular venous distention, clear lungs on auscultation, and no peripheral edema. A recent echocardiogram demonstrates a left ventricular ejection fraction of 30%30\%.

Laboratory results:
- Serum sodium: 138138 mEq/L
- Serum potassium: 4.34.3 mEq/L
- Serum creatinine: 1.11.1 mg/dL
- Estimated glomerular filtration rate: 6868 mL/min/1.73 m21.73 \text{ m}^2

Which of the following pharmacologic interventions are indicated to improve this patient's long-term survival? (Select all that apply)

  1. Oral metoprolol succinateAnswer
  2. Oral dapagliflozinAnswer
  3. Oral spironolactoneAnswer
  4. D
    Oral sacubitril-valsartan
  5. E
    Oral verapamil

Answer

The indicated interventions are oral metoprolol succinate, oral dapagliflozin, and oral spironolactone.
The correct combination of therapies includes a cardioselective beta-blocker, an SGLT2 inhibitor, and a mineralocorticoid receptor antagonist. These three drug classes are foundational elements of guideline-directed medical therapy for heart failure with reduced ejection fraction, providing proven mortality and hospitalization benefits. The patient has appropriate blood pressure, heart rate, potassium levels, and renal function to initiate all three simultaneously.

Step-by-Step Solution

1
Identify the primary clinical condition and patient status.
The patient has heart failure with reduced ejection fraction (HFrEF) with an ejection fraction of 30% and NYHA Class II symptoms following a recent myocardial infarction.
Establishing the functional class and left ventricular function determines which therapeutic guidelines apply.
2
Determine the pillars of guideline-directed medical therapy (GDMT) for HFrEF.
Standard GDMT requires a beta-blocker, a renin-angiotensin system inhibitor (preferably an ARNI), a mineralocorticoid receptor antagonist (MRA), and an SGLT2 inhibitor.
These four classes provide additive mortality and morbidity benefits in HFrEF.
3
Evaluate the patient's medical history for contraindications to GDMT components.
The patient has a history of severe angioedema from lisinopril (an ACE inhibitor).
A history of ACE inhibitor-induced angioedema is an absolute contraindication to the use of any ACE inhibitor or ARNI (sacubitril-valsartan).
4
Select the appropriate, safe medications from the available options.
Metoprolol succinate, dapagliflozin, and spironolactone are indicated and safe. Sacubitril-valsartan is contraindicated due to allergy. Verapamil is contraindicated due to its negative inotropic effect.
This establishes a comprehensive, safe, and guideline-concordant regimen that avoids critical errors.

Key Concept

Guideline-directed medical therapy for HFrEF includes four main pillars, but absolute contraindications (such as a history of ACE inhibitor-induced angioedema precluding the use of an ARNI) must be rigorously identified and avoided.
Estimated Time:1m 30s
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Pharmacologic Interventions

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