What medications can be prescribed to a patient with nonischemic cardiomyopathy, mitral regurgitation, and left bundle branch block, currently on lisinopril (Angiotensin-Converting Enzyme Inhibitor) and empagliflozin (Sodium-Glucose Cotransporter 2 Inhibitor), presenting with shortness of breath and orthopnea?

Immediate Symptomatic Management for Acute Decompensated Heart Failure

Add a loop diuretic (furosemide 20-40 mg orally) immediately to relieve congestion, and initiate a beta-blocker (bisoprolol, carvedilol, or metoprolol succinate) at low dose once symptoms stabilize, as this patient is critically undertreated with guideline-directed medical therapy despite having nonischemic cardiomyopathy. 1

Critical Gap in Current Therapy

This patient has severe symptomatic heart failure with reduced ejection fraction (HFrEF) but is missing two of the four foundational medications that reduce mortality and hospitalization:

• Missing beta-blocker: One of the most critical omissions, as beta-blockers provide early and striking reduction in overall mortality and are particularly effective in reducing sudden cardiac death 1
• Missing mineralocorticoid receptor antagonist (MRA): Should be added for patients with NYHA class II-IV symptoms despite ACE inhibitor therapy 1

Immediate Management Algorithm

Step 1: Address Acute Congestion (Start Today)

• Furosemide 20-40 mg orally daily to relieve orthopnea and dyspnea 1, 2
• Diuretics improve symptoms, exercise capacity, and reduce heart failure hospitalizations 1
• Monitor daily weights, with goal of 1-2 lb loss per day until euvolemic 1
• Check serum creatinine and potassium after 5-7 days 1

Step 2: Initiate Beta-Blocker (Within 24-48 Hours After Diuresis Begins)

Start one of these three evidence-based beta-blockers at LOW dose 1:

• Carvedilol 3.125 mg twice daily, OR
• Metoprolol succinate 12.5-25 mg daily, OR
• Bisoprolol 1.25 mg daily

Critical timing: Beta-blockers should be started once the patient is stabilized on diuretics, not delayed until "optimal" medical therapy is achieved 1

Rationale: Beta-blockers are complementary to ACE inhibitors and provide substantial improvement in ejection fraction through reverse LV remodeling 1. They reduce mortality by 34% in HFrEF patients 1, 3

Step 3: Add Mineralocorticoid Receptor Antagonist (Within 1-2 Weeks)

• Spironolactone 12.5-25 mg daily (preferred initial dose) 1
• Check potassium and creatinine at baseline, then 5-7 days after initiation 1
• Contraindicated if eGFR <30 mL/min/1.73 m² or potassium >5.0 mEq/L 1
• Reduces mortality and HF hospitalization by 30% when added to ACE inhibitor and beta-blocker 1

Step 4: Uptitrate All Medications Over 8-12 Weeks

Target doses 1:

• Lisinopril: 20-40 mg daily
• Empagliflozin: Continue current dose (already on SGLT2i)
• Beta-blocker: Carvedilol 25 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily
• Spironolactone: 25-50 mg daily

Titration strategy: Increase doses every 1-2 weeks as tolerated, monitoring blood pressure, heart rate, potassium, and creatinine 1

Special Considerations for This Patient

Left Bundle Branch Block (LBBB) with QRS ≥150 ms

• Cardiac resynchronization therapy (CRT) is Class I recommendation if LVEF ≤35% persists after 3 months of optimal GDMT 1
• CRT improves symptoms, survival, and reduces morbidity in symptomatic HF patients with sinus rhythm, LVEF ≤35%, and LBBB morphology with QRS ≥150 ms 1
• However, medical therapy optimization must occur first—the majority of LBBB-associated cardiomyopathy patients show reverse remodeling with proper GDMT 4

Mitral Regurgitation Management

• Guideline-directed medical therapy, including RAAS inhibition and beta-blockers, improves secondary MR and LV dimensions in HFrEF patients 1
• Sacubitril-valsartan (ARNi) may provide additional benefit for MR reduction compared to ACE inhibitors alone 1
• Consider upgrading lisinopril to sacubitril-valsartan after beta-blocker and MRA are stable (typically after 4-8 weeks) 1

BNP of 268 pg/mL

• Mildly elevated but not severely elevated, suggesting moderate decompensation 1
• Serial BNP monitoring can guide diuretic therapy and assess response to GDMT 1

Common Pitfalls to Avoid

Do NOT delay beta-blocker initiation until "maximum medical therapy" is achieved—this is outdated practice. Beta-blockers and ACE inhibitors should both be started as soon as possible after diagnosis 1

Do NOT start beta-blocker during severe volume overload—wait 24-48 hours after diuresis begins, but do not wait for complete euvolemia 1

Do NOT use diltiazem or verapamil—these calcium channel blockers increase risk of HF worsening and hospitalization in HFrEF 1

Do NOT combine ACE inhibitor + ARB + MRA—this triple combination increases risk of renal dysfunction and hyperkalemia 1

Monitor potassium closely—patient is on ACE inhibitor, SGLT2i, and will be adding MRA. Check potassium 5-7 days after each medication change 1

Monitoring Parameters

Weekly for first month 1:

• Blood pressure and heart rate
• Daily weights
• Symptoms (orthopnea, dyspnea, edema)

Laboratory monitoring 1:

• Potassium and creatinine: 5-7 days after each medication change
• Then monthly for 3 months
• Then every 3-6 months once stable

Reassess LVEF in 3 months to determine need for ICD or CRT 1