What is the best next step in managing a patient with heart failure with reduced ejection fraction (HFrEF) currently on losartan (angiotensin II receptor blocker), carvedilol (beta-blocker), and furosemide (loop diuretic)?

Management of Heart Failure with Reduced Ejection Fraction

The most appropriate next step for this 57-year-old man with newly diagnosed heart failure with reduced ejection fraction (HFrEF) is to switch losartan to sacubitril-valsartan (option B). 1, 2, 3

Rationale for Sacubitril-Valsartan

This patient presents with:

• New diagnosis of HFrEF (EF 35%)
• Currently on losartan (ARB)
• Symptoms of decompensated heart failure (shortness of breath, lower extremity edema)
• Elevated BNP
• Evidence of pulmonary edema on chest X-ray

Sacubitril-valsartan (ARNI) is superior to ARBs alone in reducing:

• Cardiovascular mortality
• Heart failure hospitalizations
• Overall morbidity in patients with HFrEF 3

The FDA-approved indication for sacubitril-valsartan specifically includes "reducing the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction." 2

Dosing Considerations

• Starting dose: 49/51 mg twice daily
• Target dose: 97/103 mg twice daily after 2-4 weeks, as tolerated 1, 2
• A 36-hour washout period is required when switching from an ACE inhibitor to sacubitril-valsartan 2
• Since the patient is currently on an ARB (losartan), no washout period is needed

Why Not the Other Options?

1. Option A (Switch dapagliflozin to sitagliptin):

   • SGLT2 inhibitors like dapagliflozin have proven mortality benefits in HFrEF 1, 4
   • Removing dapagliflozin would eliminate these benefits
   • Recent evidence shows that combination therapy with ARNI and SGLT2 inhibitors provides additive mortality reduction 4

2. Option C (Switch carvedilol to long-acting metoprolol):

   • Both are appropriate beta-blockers for HFrEF 1
   • No clear evidence that metoprolol provides superior outcomes compared to carvedilol in this setting
   • Changing beta-blockers would not address the need to optimize RAAS inhibition

3. Option D (Add hydrochlorothiazide to furosemide):

   • While combination diuretic therapy can be useful for resistant fluid overload 5
   • This approach doesn't address the need for disease-modifying therapy
   • The patient is already receiving IV diuretics for acute management

Comprehensive HFrEF Management

The optimal approach for this patient should include:

1. Continue SGLT2 inhibitor (dapagliflozin) - provides mortality benefit independent of glycemic control 1, 4

2. Switch losartan to sacubitril-valsartan - superior to ARB alone for reducing mortality and hospitalizations 1, 2, 3

3. Continue beta-blocker (carvedilol) - essential component of HFrEF therapy 1

4. Consider adding an MRA (spironolactone or eplerenone) if not contraindicated by renal function or potassium levels 1

5. Continue loop diuretic (furosemide) for symptom management and volume control 5, 1

Monitoring Considerations

• Monitor renal function and potassium levels closely after initiating sacubitril-valsartan
• Watch for hypotension, especially during up-titration
• Assess volume status regularly
• Continue to optimize glycemic control (current HbA1c 8.5%)

Common Pitfalls to Avoid

• Failure to implement quadruple therapy: ARNI/ACEI/ARB + beta-blocker + MRA + SGLT2i provides the most significant mortality benefit
• Discontinuing beta-blockers during acute decompensation: Guidelines recommend continuing beta-blockers in most patients unless hemodynamically unstable 5
• Inadequate dosing: Aim for target doses of heart failure medications whenever possible
• Overlooking the value of SGLT2 inhibitors: These provide mortality benefit regardless of diabetes status

By switching from losartan to sacubitril-valsartan while maintaining the other components of guideline-directed medical therapy, this patient will receive the most evidence-based approach to reducing mortality and improving quality of life.