From the Guidelines
The most appropriate medication for this patient is lisinopril (option E). This 68-year-old man with heart failure with reduced ejection fraction (HFrEF) of 42% would benefit from an angiotensin-converting enzyme (ACE) inhibitor like lisinopril as part of standard guideline-directed medical therapy, as recommended by the European Journal of Heart Failure 1. ACE inhibitors have been shown to reduce mortality, decrease hospitalizations, and improve symptoms in patients with HFrEF. The patient already takes carvedilol, a beta-blocker, which is another cornerstone of heart failure therapy. Adding lisinopril would provide complementary benefits by reducing afterload, preventing adverse cardiac remodeling, and improving cardiac output.
The patient's blood pressure of 128/68 mmHg is adequate to tolerate ACE inhibitor therapy. While the patient has COPD, an ACE inhibitor would not worsen his respiratory status, as stated in the European Heart Journal 1. Lisinopril would also help manage his left ventricular hypertrophy. The other medication options are less appropriate:
- amiodarone is an antiarrhythmic not indicated without documented arrhythmias
- diltiazem can worsen heart failure
- ezetimibe addresses cholesterol but not heart failure
- and hydrochlorothiazide alone is insufficient for heart failure management. The 2020 ACC/AHA clinical performance and quality measures for adults with heart failure also support the use of ACE inhibitors, such as lisinopril, as a key component of guideline-directed medical therapy for patients with HFrEF 1. Additionally, the ACC/AHA versus ESC guidelines on heart failure comparison highlights the importance of ACE inhibitors in the management of symptomatic HF due to HFrEF 1.
Some key points to consider when prescribing lisinopril include:
- Starting with a low dose and titrating up to the target dose, as outlined in the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1
- Monitoring the patient's blood pressure, renal function, and electrolyte levels, as recommended by the European Journal of Heart Failure 1
- Adjusting the dose as needed to achieve optimal blood pressure control and minimize adverse effects, as stated in the European Heart Journal 1.
Overall, the use of lisinopril in this patient is supported by the latest clinical guidelines and evidence-based recommendations, and is expected to improve his outcomes and quality of life.
From the FDA Drug Label
- 2 Heart Failure In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance.
The most appropriate medication for this patient is lisinopril. The patient has been diagnosed with new-onset heart failure secondary to diastolic dysfunction and has an ejection fraction of 42%, indicating systolic heart failure. The use of lisinopril in heart failure is supported by clinical studies, which have shown that it reduces signs and symptoms of heart failure and improves exercise tolerance 2.
- Key benefits of lisinopril in this patient include:
- Reduction of edema
- Improvement of exercise tolerance
- Decrease in symptoms of heart failure, such as orthopnea and paroxysmal nocturnal dyspnea
- Current medication regimen already includes carvedilol, which is a beta blocker, and the addition of lisinopril, an ACE inhibitor, would be a common and evidence-based combination for the treatment of heart failure.
From the Research
Patient's Condition
The patient is a 68-year-old man with new-onset heart failure secondary to diastolic dysfunction, and has a history of chronic obstructive pulmonary disease, hypercholesterolemia, and osteoarthritis.
Current Medications
The patient is currently taking carvedilol, simvastatin, and glucosamine.
Recent Echocardiogram Results
The recent echocardiogram revealed an ejection fraction of 42% and moderate left ventricular hypertrophy.
Vital Signs and Physical Examination
The patient's vital signs are:
- Blood pressure: 128/68 mmHg
- Heart rate: 62/min
- Oxygen saturation: 92% on room air The physical examination reveals:
- Regular heart rate and rhythm
- S, but no murmur
- Clear lungs to auscultation
- Bilateral inhalation dysfunction at ribs 2-7
- 1+ bilateral lower extremity edema
Most Appropriate Medication
Based on the patient's condition and the studies provided, the most appropriate medication for this patient is:
- E. lisinopril The use of lisinopril is supported by several studies, including 3, 4, 5, and 6, which demonstrate its efficacy in reducing mortality and morbidity in patients with heart failure. Additionally, study 7 highlights the benefits of combining beta-blockers, such as carvedilol, with ACE inhibitors, like lisinopril, in the management of chronic heart failure.
Key Points
- Lisinopril is an ACE inhibitor that has been shown to reduce mortality and morbidity in patients with heart failure 3, 4, 5, 6.
- The combination of beta-blockers and ACE inhibitors provides an additive benefit in improving long-term survival and reducing heart failure-related hospitalizations 7.
- Lisinopril is generally well tolerated and has a good safety profile 3, 4, 6.