From the Guidelines
For a patient with heart failure with reduced ejection fraction (HFrEF), hypertension, and type 1 diabetes, dapagliflozin should be added to their medication regimen, as it has been shown to reduce the risk of heart failure hospitalization and cardiovascular death, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. The patient's presentation with dyspnea on exertion, bilateral lower extremity swelling, early satiety, and 3 pillow orthopnea, along with a left ventricular ejection fraction of 35% and global hypokinesis, is consistent with HFrEF. The presence of type 1 diabetes and hypertension further supports the use of dapagliflozin, as it has been shown to have beneficial effects in patients with diabetes and heart failure. Key benefits of dapagliflozin include:
- Reduction in heart failure hospitalization and cardiovascular death
- Improvement in symptoms and quality of life
- Renoprotective effects, which are particularly important in diabetic patients
- Can be used in patients with HFrEF, regardless of the presence of diabetes The dosage of dapagliflozin should be started at 10 mg daily, as recommended by the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. Other medications, such as ACE inhibitors or ARBs, beta-blockers, and mineralocorticoid receptor antagonists, may also be considered as part of the patient's treatment regimen, but dapagliflozin is a key addition for patients with HFrEF, hypertension, and type 1 diabetes.
From the Research
Medication Options for Heart Failure with Reduced Ejection Fraction (HFrEF)
The patient's condition, characterized by heart failure with reduced ejection fraction (HFrEF), hypertension, and type 1 diabetes, requires careful consideration of medication options to improve outcomes. The following points summarize the potential medications that could be added to the patient's regimen:
- Sacubitril/Valsartan: This angiotensin receptor-neprilysin inhibitor (ARNI) has been shown to reduce cardiac mortality and rehospitalization in patients with HFrEF 2, 3, 4, 5. The combination of sacubitril/valsartan with dapagliflozin has also demonstrated benefits in reducing cardiac mortality 2.
- Dapagliflozin: As a sodium-glucose cotransporter-2 (SGLT2) inhibitor, dapagliflozin has been found to reduce rehospitalization and cardiac mortality in patients with HFrEF, particularly when used in combination with sacubitril/valsartan 2, 3.
- Lisinopril: An angiotensin-converting enzyme (ACE) inhibitor, lisinopril is commonly used in the treatment of heart failure and hypertension. However, in the context of HFrEF, sacubitril/valsartan may be preferred over ACE inhibitors due to its superior benefits in reducing mortality and morbidity 3, 5.
- Metoprolol Tartrate: A beta-blocker, metoprolol tartrate is often used in the management of heart failure and hypertension. While it is an important component of heart failure treatment, the question specifically asks which medication should be added to the patient's regimen, implying that the patient may already be receiving a beta-blocker.
Considerations for the Patient's Condition
Given the patient's HFrEF, hypertension, and type 1 diabetes, the most appropriate medication to add to their regimen would be one that addresses the heart failure component directly and has shown benefits in reducing cardiac mortality and morbidity.
Recommended Medication
Based on the evidence, Sacubitril/Valsartan (D) would be the most appropriate choice to add to the patient's regimen, considering its established benefits in reducing cardiac mortality and rehospitalization in patients with HFrEF 2, 3, 4, 5. Additionally, Dapagliflozin (A) could also be considered, especially if used in combination with sacubitril/valsartan, as it has shown to further reduce cardiac mortality in HFrEF patients 2. However, between the two, sacubitril/valsartan is more directly indicated for HFrEF management.