A 45-year-old man is evaluated in the hospital prior to discharge. He was admitted three d… — USMLE Step 3

A 45-year-old man is evaluated in the hospital prior to discharge. He was admitted three days ago for acute dyspnea and was found to have a new-onset nonischemic cardiomyopathy with a left ventricular ejection fraction of 20%. He has been treated with intravenous furosemide and is now breathing comfortably on room air. He has no orthopnea, and his volume status is clinically optimized. Medical history is notable for hypertension and an episode of severe lip swelling and airway compromise requiring epinephrine after taking lisinopril two years ago. Current vital signs are blood pressure 118/75 mmHg, heart rate 72/min, and respirations 14/min.

Laboratory results obtained this morning are as follows:

Test	Result	Reference Range
Sodium	138 mEq/L	136-145 mEq/L
Potassium	5.8 mEq/L	3.5-5.0 mEq/L
Chloride	102 mEq/L	98-106 mEq/L
Bicarbonate	24 mEq/L	22-28 mEq/L
Blood urea nitrogen	22 mg/dL	8-23 mg/dL
Creatinine	1.3 mg/dL	0.7-1.3 mg/dL

Which of the following pharmacologic interventions are appropriate to initiate prior to discharge? (Select all that apply)

Metoprolol succinateCevap
DapagliflozinCevap
Isosorbide dinitrate and hydralazineCevap
D
Sacubitril-valsartan
E
Spironolactone
F
Verapamil

Cevap

The appropriate interventions to initiate are metoprolol succinate, dapagliflozin, and the combination of isosorbide dinitrate and hydralazine.

This patient requires initiation of guideline-directed medical therapy for newly diagnosed heart failure with reduced ejection fraction (HFrEF). Standard quad-therapy components generally include an ARNI/ACEi/ARB, an evidence-based beta-blocker, a mineralocorticoid receptor antagonist (MRA), and an SGLT2 inhibitor. Metoprolol succinate is an evidence-based beta-blocker that should be started in stable, euvolemic patients. Dapagliflozin reduces mortality and hospitalizations in HFrEF regardless of diabetes status and is safe given the patient's adequate renal function. Because the patient has a history of ACE-inhibitor-induced angioedema, all ACE inhibitors, ARBs, and ARNIs (e.g., sacubitril-valsartan) are strictly contraindicated. In patients who cannot tolerate these agents, the combination of isosorbide dinitrate and hydralazine is the recommended alternative to provide mortality-reducing afterload and preload reduction.

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Assess the clinical state and primary diagnosis.

The patient has newly diagnosed heart failure with reduced ejection fraction (HFrEF) with an ejection fraction of 20%, and is now euvolemic and hemodynamically stable.

Establishing baseline stability is required before safely initiating guideline-directed medical therapy (GDMT) prior to discharge.

Review the patient's medical history for contraindications to standard GDMT.

The patient has a history of life-threatening angioedema secondary to lisinopril.

A history of ACE-inhibitor-induced angioedema acts as an absolute contraindication to all ACE inhibitors, ARBs, and ARNIs (e.g., sacubitril-valsartan) due to cross-reactivity and bradykinin accumulation.

Evaluate the current laboratory values, specifically electrolytes and renal function.

The patient's serum potassium is significantly elevated at 5.8 mEq/L.

Hyperkalemia is an absolute contraindication to initiating mineralocorticoid receptor antagonists (MRAs) such as spironolactone, which would further increase potassium levels.

Select the appropriate, safe pharmacological agents to form a modified GDMT regimen.

Metoprolol succinate, dapagliflozin, and the combination of isosorbide dinitrate and hydralazine are selected.

Beta-blockers and SGLT2 inhibitors remain safe and indicated. Hydralazine and nitrates serve as the evidence-based alternative for mortality reduction in HFrEF when renin-angiotensin-aldosterone system inhibitors are contraindicated.

Anahtar Kavram

Initiation of guideline-directed medical therapy for HFrEF requires careful adjustment for absolute contraindications, specifically avoiding ARNIs/ACEis/ARBs in patients with prior angioedema and avoiding MRAs in patients with significant hyperkalemia.

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