What should be added to the treatment regimen of a patient with congestive heart failure (CHF) on Lasix (furosemide), metoprolol, and spironolactone, with a severely impaired left ventricular function (ejection fraction of 15%), to decrease the risk of mortality?

From the Guidelines

For a patient with CHF, an ejection fraction of 15%, and already on Lasix, metoprolol, and spironolactone, the most appropriate addition to decrease mortality risk is sacubitril/valsartan, as it has been shown to further 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.

Key Considerations

• The patient's severely impaired left ventricular function (ejection fraction of 15%) puts them at high risk for life-threatening complications, and optimal medical management is crucial to reduce mortality risk.
• The current treatment regimen includes a diuretic (Lasix), a beta-blocker (metoprolol), and an aldosterone antagonist (spironolactone), which are all essential components of guideline-directed medical therapy for heart failure.
• The addition of sacubitril/valsartan, as recommended by the 2016 ESC guidelines, offers a potential mortality benefit by further reducing 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.

Alternative Options

• Other pharmacological treatments, such as ivabradine, hydralazine and isosorbide dinitrate, and digoxin, may be considered in selected patients with symptomatic heart failure, but are not the most appropriate addition in this case.
• An implantable cardioverter-defibrillator (ICD) may be recommended for primary prevention of sudden cardiac death in patients with severe left ventricular systolic dysfunction, but this is not the most relevant consideration in this case, given the patient's current treatment regimen and the potential benefits of sacubitril/valsartan.

Evidence-Based Recommendation

• The 2016 ESC guidelines provide a comprehensive framework for the diagnosis and treatment of acute and chronic heart failure, and recommend sacubitril/valsartan as a replacement for an ACE-I to further 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.
• This recommendation is based on the results of clinical trials, which have demonstrated the efficacy and safety of sacubitril/valsartan in reducing mortality and morbidity in patients with heart failure.

From the FDA Drug Label

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. A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose Patients receiving lisinopril (n=9,646), alone or with nitrates, had an 11% lower risk of death (p = 0.04) compared to patients who did not receive lisinopril (n=9,672) (6.4% vs. 7. 2%, respectively) at six weeks

Lisinopril should be added to the treatment regimen of a patient with congestive heart failure (CHF) on Lasix (furosemide), metoprolol, and spironolactone, with a severely impaired left ventricular function (ejection fraction of 15%), to decrease the risk of mortality 2.

• The addition of lisinopril to the current treatment regimen may help reduce the risk of death and improve symptoms of heart failure.
• It is essential to monitor the patient's blood pressure, renal function, and overall clinical status when initiating lisinopril therapy.

From the Research

Treatment Regimen for Congestive Heart Failure (CHF)

To decrease the risk of mortality in a patient with CHF on Lasix (furosemide), metoprolol, and spironolactone, with a severely impaired left ventricular function (ejection fraction of 15%), the following options can be considered:

• Addition of an angiotensin receptor-neprilysin inhibitor (ARNI) to the treatment regimen, as it has been shown to have a favourable effect on reduction of sudden cardiac death in heart failure with reduced ejection fraction (HFrEF) 3
• Addition of a sodium-glucose cotransporter 2 inhibitor (SGLT2i) to the treatment regimen, as recent data suggest a beneficial effect of SGLT2i in reducing serious ventricular arrhythmias and sudden cardiac death in patients with HFrEF 3
• Consideration of implantable cardioverter-defibrillator (ICD) implantation for primary prevention of sudden death, although the benefit of ICD in patients with HFrEF of non-ischaemic aetiology is less strong 3, 4
• Optimization of guideline-directed medical therapy (GDMT) for HFrEF, as contemporary GDMT confers a significant mortality benefit for patients with HFrEF, and each additional GDMT medication prescribed at the time of device implantation is associated with a reduction in the risk of death 5

Key Considerations

• The patient's severely impaired left ventricular function (ejection fraction of 15%) is a significant predictor of mortality, and treatment strategies should be aimed at reducing the risk of sudden cardiac death 6, 7
• The use of ICD for primary prevention of sudden death should be carefully considered, taking into account the patient's individual risk factors and the potential benefits and risks of the device 4, 5
• The optimization of GDMT for HFrEF is crucial, and the addition of ARNI and SGLT2i to the treatment regimen may be beneficial in reducing the risk of mortality 3, 5