What additional medications are recommended for a 77-year-old man with newly diagnosed heart failure with reduced ejection fraction (HFrEF), already on telmisartan (Angiotensin II receptor antagonist), metoprolol (Beta blocker), and Sodium-Glucose Cotransporter 2 inhibitors (SGLT2), with a history of coronary artery bypass grafting (CABG), hypertension, diabetes mellitus, and dyslipidemia?

From the Guidelines

For this 77-year-old man with newly diagnosed heart failure with reduced ejection fraction (HFrEF, LVEF 39%), I would recommend adding an aldosterone antagonist (spironolactone 25mg daily or eplerenone 25mg daily) to his current regimen of telmisartan, metoprolol, and SGLT2 inhibitor. Additionally, consider adding sacubitril/valsartan (Entresto) to replace telmisartan, starting at 24/26mg twice daily and titrating up as tolerated, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. If the patient remains symptomatic despite these medications, adding isosorbide dinitrate/hydralazine combination could be beneficial, particularly given his history of coronary artery disease. Monitor renal function, potassium levels, and blood pressure closely when initiating these medications, especially the aldosterone antagonist, as recommended in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. Dosage adjustments may be necessary based on tolerance and laboratory values. These medications have been shown to reduce mortality, hospitalizations, and improve symptoms in patients with HFrEF by targeting different pathophysiological mechanisms including the renin-angiotensin-aldosterone system and sympathetic nervous system overactivation that contribute to adverse cardiac remodeling. Key considerations include:

• Starting doses and target doses for GDMT, as outlined in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1
• The importance of titrating medications to maximally tolerated doses, as recommended in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1
• The potential benefits and risks of each medication, including the risk of worsening renal function or hyperkalemia with certain medications, as discussed in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1

From the FDA Drug Label

The safety and effectiveness of sacubitril and valsartan have been established for the treatment of heart failure in pediatric patients 1 year to less than 18 years No overall differences in safety or effectiveness of sacubitril and valsartan have been observed between patients 65 years of age and older and younger adult patients Sacubitril and valsartan tablet is a combination of a neprilysin inhibitor and an angiotensin II receptor blocker

The patient is already on telmisartan, an angiotensin II receptor blocker, metoprolol, a beta blocker, and SGLT2 inhibitor. To add sacubitril and valsartan to the treatment, it is necessary to stop the angiotensin II receptor blocker (telmisartan) to avoid duplication of therapy.

• Sacubitril and valsartan can be added to the treatment as it is a combination of a neprilysin inhibitor and an angiotensin II receptor blocker.
• The patient's age (77 years) does not contraindicate the use of sacubitril and valsartan 2.

From the Research

Guideline-Directed Medical Therapy (GDMT) for CHFrEF

The patient is already on telmisartan, metoprolol, and SGLT2 inhibitors. To optimize GDMT, consider the following:

• Replace telmisartan with an angiotensin receptor-neprilysin inhibitor (ARNI) such as sacubitril/valsartan, as studies have shown that ARNI is superior to ACEI in reducing mortality and HF hospitalization and in improving quality of life in patients with stage C HFrEF 3, 4, 5.
• Continue metoprolol as a beta-blocker, as it is a core medical therapy for patients with HFrEF 6.
• Continue SGLT2 inhibitors, as they have been shown to improve outcomes in patients with HF regardless of their diabetic status 6.

Additional Therapies

Consider adding the following therapies as adjuncts to the core therapies:

• Ivabradine to slow heart rate in patients with sinus rhythm, if indicated 6.
• Hydralazine/isosorbide dinitrate combination to unload the heart, if indicated 6.
• Mineralocorticoid receptor antagonists, if not already on one, as they are a core medical therapy for patients with HFrEF 6.

Key Considerations

• The patient's current medications and medical history should be carefully evaluated before making any changes to their treatment plan.
• The patient's response to the new medications and any potential side effects should be closely monitored.