AANP Family Nurse Practitioner (FNP) Certification ExamPlanMedium
A 72-year-old female with a history of heart failure with reduced ejection fraction (HFrEF) presents with worsening dyspnea and lower extremity edema. Her current medications include lisinopril, carvedilol, and furosemide. Her blood pressure is 108/68 mmHg, and potassium is 4.1 mEq/L. Which of the following pharmacological adjustments is most appropriate for this patient?
- AAdd digoxin.
- BIncrease carvedilol dose.
- CIncrease furosemide dose.
- DAdd spironolactone.
Show answer & explanationAnswer & explanation
Correct answer: D. Add spironolactone.
In patients with HFrEF and persistent symptoms despite ACE inhibitor/ARB and beta-blocker therapy, adding a mineralocorticoid receptor antagonist (MRA) such as spironolactone is recommended. MRAs have been shown to reduce morbidity and mortality in HFrEF, and her potassium level is within an acceptable range for initiation.
Why the other options are wrong
- A. Digoxin may be considered for symptom control in HFrEF, but it does not have the mortality benefit seen with MRAs and is typically added after other guideline-directed therapies are optimized.
- B. Increasing carvedilol should be done cautiously in acutely decompensated heart failure and is not the primary next step when an MRA is indicated for mortality benefit.
- C. Increasing furosemide might help with fluid overload, but it doesn't address the mortality benefit offered by MRAs in HFrEF and is not the most appropriate next step for long-term management.
HFrEF Guideline-Directed Medical Therapy (GDMT)
GDMT for HFrEF includes ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists (MRAs) to reduce morbidity and mortality.
- MRAs (e.g., spironolactone, eplerenone) are recommended for all HFrEF patients with NYHA class II-IV symptoms.
- Monitor potassium and renal function closely after initiating MRAs.
- MRAs provide significant mortality benefits beyond ACEIs/ARBs and beta-blockers.
Memory trick: ACE, Beta, MRA: The Core Heart Failure Trio.