A 62-year-old Caucasian man with a history of diabetes and a myocardial infarction 2 years ago is hospitalized for acute decompensated heart failure. He is diuresed with improvement in symptoms and is discharged on appropriate medications. He is seen in clinic 4 months later with complaints of worsening symptoms over the last month. Previously he became mildly short of breath after significant exertion, but he now reports severe shortness of breath after walking only 50 m. He is asymptomatic only at rest. His current medications include aspirin, captopril, carvedilol, furosemide, atorvastatin, omega-3 fatty acids, and pantoprazole. An ECG performed in the office shows Q waves in leads V3 and V4, with a normal QRS duration. An echocardiogram performed 1 week ago showed an ejection fraction of 35%.
The patient has been encouraged to quit smoking and drinking alcohol, and to eat a low-sodium diet. What additional therapy is recommended at this time?
A. Losartan: Spironolactone. This question tests the reader’s understanding of chronic heart failure treatment. The patient displays New York Heart Association (NYHA) class III symptoms (no symptoms at rest, but symptoms with minimal exertion), and therefore needs an escalation in his treatment. He is on an appropriate initial regimen, which includes a loop diuretic, an ACE inhibitor, and a β-blocker. Angiotensin receptor blockers (ARBs) are appropriate alternatives to ACE inhibitors, but should not be used in conjunction with ACE inhibitors. The three β-blockers shown to have a survival benefit in heart failure are carvedilol, metoprolol, and bisoprolol, so one of these agents is usually used. This patient is symptomatic and needs the next step in therapy, which is an aldosterone antagonist (e.g., spironolactone). These agents reduce mortality in patients with NYHA class III/IV with a reduced ejection fraction (≤35%), or in patients with heart failure that have suffered a previous myocardial infarction. Notable side effects of spironolactone include hyperkalemia, gynecomastia, and agranulocytosis. If the patient is still symptomatic, digoxin may be prescribed although there is no mortality benefit with this agent. The patient should also consider an ICD given his history of myocardial infarction and reduced ejection fraction. ICDs have been shown to reduce mortality, both for primary prevention and for secondary prevention of fatal arrhythmias.
(A) The patient is already on an ACE inhibitor, and there is no benefit to adding an angiotensin receptor blocker. (C) Cardiac resynchronization therapy (CRT) may be considered in heart failure patients with dyssynchrony between the left and right ventricles, and therefore criteria for CRT includes a QRS duration >120 ms. This patient does not meet criteria. (D) Hydralazine and nitrates are used as alternatives to ACE inhibitors and ARBs if the patient cannot tolerate one of these agents. Hydralazine and nitrates are especially beneficial for African Americans, but this patient is Caucasian.