A 72-year-old male with a history of chronic heart failure with preserved ejection fraction (HFpEF) presents with increasing dyspnea on exertion and lower extremity edema. He is currently on lisinopril and furosemide. His blood pressure is 140/85 mmHg, and his heart rate is 70 bpm. Which of the following pharmacological additions is most appropriate to improve his symptoms and reduce hospitalizations in HFpEF?
- AMetoprolol succinate
- BSpironolactone
- CDigoxin
- DHydralazine/Isosorbide dinitrate
Show answer & explanationAnswer & explanation
Correct answer: B. Spironolactone
Mineralocorticoid receptor antagonists (MRAs) like spironolactone or eplerenone are strongly recommended in patients with HFpEF to reduce hospitalizations and improve quality of life. Recent guidelines (e.g., 2022 ACC/AHA/HFSA) specifically endorse MRAs for HFpEF patients, especially those with elevated natriuretic peptides or prior heart failure hospitalization. Digoxin is not indicated for HFpEF. Beta-blockers (metoprolol) and hydralazine/isosorbide dinitrate are not proven to have the same robust benefits in HFpEF as they do in HFrEF.
Why the other options are wrong
- A. Metoprolol succinate (beta-blocker) is a cornerstone in HFrEF but has not shown consistent benefits in reducing morbidity/mortality in HFpEF.
- C. Digoxin is primarily used for HFrEF with atrial fibrillation or severe symptoms, not indicated for HFpEF.
- D. Hydralazine/isosorbide dinitrate is primarily for HFrEF, particularly in African Americans, and is not a first-line therapy for HFpEF.
HFpEF Guideline-Directed Medical Therapy (GDMT)
Guideline-directed medical therapy for Heart Failure with preserved Ejection Fraction (HFpEF) focuses on managing comorbidities and includes mineralocorticoid receptor antagonists (MRAs), SGLT2 inhibitors, ARBs, and ARNI to reduce hospitalizations and improve outcomes.
- MRAs (spironolactone, eplerenone) are recommended for HFpEF.
- SGLT2 inhibitors are also now recommended for HFpEF.
- Control hypertension and manage fluid overload with diuretics.
- Beta-blockers, ACEIs, ARBs are not universally beneficial like in HFrEF.
Memory trick: HFpEF's a fight? MRAs make it right!