What medication should be prescribed to a patient with heart failure with reduced ejection fraction (HFrEF) upon discharge?

From the Guidelines

The patient should be prescribed Sacubitril/valsartan upon discharge, as it has been shown to reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.

The patient's current medication regimen includes carvedilol, which is a beta-blocker, and furosemide, which is a diuretic. However, the patient is not currently taking an ACE inhibitor or an ARNI, which are essential components of guideline-directed medical therapy (GDMT) for HFrEF. Sacubitril/valsartan is a preferred option for patients with HFrEF, as it has been shown to be more effective than ACE inhibitors in reducing the risk of HF hospitalization and death 1.

In addition to Sacubitril/valsartan, the patient should also be considered for an SGLT2 inhibitor, such as empagliflozin, which has been shown to reduce the risk of HF hospitalization and cardiovascular death in patients with HFrEF 1. However, the patient's current renal function and other comorbidities should be taken into consideration before initiating an SGLT2 inhibitor.

The patient's potassium level is elevated, which may be a concern when initiating Sacubitril/valsartan or an SGLT2 inhibitor. However, the benefits of these medications in reducing morbidity and mortality in patients with HFrEF outweigh the potential risks, and careful monitoring of the patient's potassium level and renal function can help mitigate these risks 1.

Overall, the patient should be prescribed Sacubitril/valsartan upon discharge, with careful consideration of the patient's renal function, potassium level, and other comorbidities. The patient should also be considered for an SGLT2 inhibitor, and the patient's medication regimen should be optimized to achieve the best possible outcomes.

Some key points to consider when prescribing Sacubitril/valsartan include:

• The patient should be stable and not have any contraindications to the medication
• The patient's blood pressure should be monitored closely, as Sacubitril/valsartan can cause hypotension
• The patient's renal function and potassium level should be monitored closely, as Sacubitril/valsartan can cause changes in these parameters
• The patient should be educated on the importance of adherence to the medication regimen and follow-up appointments to monitor the patient's condition.

From the FDA Drug Label

Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure. Benefits are most clearly evident in patients with left ventricular ejection fraction (LVEF) below normal The patient has a left ventricular ejection fraction of 40%, which is below normal. Sacubitril/valsartan is indicated for this patient, as it reduces the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure, particularly those with reduced ejection fraction.

• The recommended starting dose is 49/51 mg orally twice-daily, and the dose can be doubled after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily, as tolerated by the patient 2. However, the patient is already on an ACE inhibitor (aspirin is not an ACE inhibitor but the patient was on other medications and the label does not specify the current medication regimen), and a 36-hour washout period is required before starting sacubitril/valsartan. Given the information provided and the fact that the patient has heart failure with reduced ejection fraction (HFrEF), the best choice is D. Sacubitril/valsartan.

From the Research

Medication Options for Heart Failure with Reduced Ejection Fraction (HFrEF)

The patient in question has been diagnosed with heart failure with reduced ejection fraction (HFrEF), as indicated by an echocardiogram showing a left ventricular ejection fraction of 40%. Given this diagnosis, the most appropriate medication options should be considered to improve outcomes.

Current Evidence

Studies have shown that sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), is effective in reducing mortality and morbidity in patients with HFrEF 3, 4, 5. The PARADIGM-HF trial demonstrated a 20% reduction in the incidence rate of death or HF hospitalization compared to enalapril in symptomatic HFrEF patients 5.

Medication Comparison

Comparing the medication options:

• Sacubitril/valsartan (D): Shown to improve outcomes in HFrEF patients, including reduced mortality and morbidity 3, 4, 5, 6, 7.
• Empagliflozin (A): While effective in reducing cardiovascular events in patients with type 2 diabetes, its use in HFrEF is not as well established as sacubitril/valsartan.
• Lisinopril (B): An angiotensin-converting enzyme inhibitor (ACEi), which is a standard treatment for HFrEF, but sacubitril/valsartan has been shown to be more effective in reducing mortality and morbidity.
• Spironolactone (C): A mineralocorticoid receptor antagonist, which is used in HFrEF treatment, but not as a first-line option compared to sacubitril/valsartan.

Recommendation

Based on the current evidence, sacubitril/valsartan (D) is the most appropriate medication option for this patient with HFrEF, as it has been shown to improve outcomes and reduce mortality and morbidity 3, 4, 5, 6, 7.