A 55-year-old man presents with gradually increasing shortness of breath and leg swelling that occurred while on a business trip. He has congestive heart failure, which has caused fatigue and shortness of breath if he walks a block or climbs a flight of stairs. Blood pressure is 140/90; there is no jugular venous distension or gallop, and only minimal pedal edema. An echocardiogram shows left ventricular ejection fraction is 45%. Current medications include aspirin and simvastatin. The patient desires to keep medications to a minimum. What additional treatments are indicated at this time?
A. SpironolactoneThere is very good evidence that ACE inhibitors should be used in patients with symptomatic and asymptomatic congestive heart failure (a depressed left ventricular ejection fraction < 40%). ACE inhibitors stabilize left ventricular remodeling, improve symptoms, reduce hospitalization, and decrease mortality. Beta-blocker therapy represents a major advance in the treatment of patients with congestive heart failure. These drugs interfere with the harmful effects of sustained activation of the adrenergic nervous system (α1 , β1 , and β2 ) by competitively blocking their receptors. When given with ACE inhibitors, beta-blockers stabilize left ventricular remodeling, improve patient symptoms, reduce hospitalization, and decrease mortality. An aldosterone antagonist is recommended for patients with NYHA class III or IV symptoms who have a left ventricular ejection fraction of less than 35% and who are still symptomatic despite receiving standard therapy with diuretics, ACE inhibitors, and beta-blockers. Likewise, digoxin may improve symptoms of patients with advanced symptomatic congestive heart failure. Neither of these drugs is indicated in this patient with mild symptoms. Furosemide is used to improve symptoms but does not prolong survival. Since this patient wants to minimize medications, an ACE inhibitor and beta-blocker are better first choices because they confer a survival advantage. An implantable defibrillator is indicated in systolic heart failure with left ventricular ejection fraction less than 30% to 35% in order to prevent sudden cardiac death, but is not indicated in this patient whose ejection fraction is 45%.