What is the most appropriate next step in managing a patient with heart failure due to left ventricular dysfunction, currently on enalapril (Angiotensin-Converting Enzyme inhibitor) and furosemide (loop diuretic), with normal heart sounds, clear chest, no peripheral edema, normal blood pressure, and a heart rate of 76 beats per minute?

Management of Heart Failure with Left Ventricular Dysfunction

The most appropriate next step is to add bisoprolol (Option C), as beta-blockers are first-line therapy alongside ACE inhibitors for all patients with stable heart failure due to left ventricular systolic dysfunction, regardless of symptom severity. 1, 2

Rationale for Beta-Blocker Initiation

This patient is currently on enalapril (ACE inhibitor) and furosemide (diuretic) but is missing a critical component of guideline-directed medical therapy. Beta-blockers should be initiated as first-line treatment along with ACE inhibitors in all patients with left ventricular systolic dysfunction, even when patients appear clinically stable. 1, 3

Evidence Supporting Beta-Blocker Use

• Beta-blockers reduce mortality by 34%, representing the highest relative risk reduction among the four foundational medication classes for heart failure with reduced ejection fraction 2
• The American College of Cardiology recommends initiating all four medication classes (ACE inhibitor/ARB/ARNi, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors) early in the disease course for patients with HFrEF 2
• Beta-blockers improve symptoms, functional status, reduce hospitalizations, and increase survival in patients with NYHA class II-IV heart failure 1, 4

Why Bisoprolol Specifically

Only three beta-blockers have proven mortality benefit in heart failure: bisoprolol, carvedilol, and metoprolol succinate (CR/XL). 1 The benefits of beta-blockers cannot be assumed to be a class effect, and other beta-blockers may be ineffective 1

• Bisoprolol starting dose: 1.25 mg once daily 1
• Target dose: 10 mg once daily 1
• Doses should be doubled at not less than 2-week intervals as tolerated 1

Why Not the Other Options

Option A: Digoxin

• Digoxin is not first-line therapy and is primarily used for rate control in atrial fibrillation or as adjunctive therapy in patients who remain symptomatic despite optimal medical therapy 1
• This patient has a normal heart rate (76 bpm) and no mention of atrial fibrillation 1

Option B: Losartan (ARB)

• ACE inhibitors have a stronger evidence base than ARBs and should be preferred 1, 3
• ARBs are only recommended when ACE inhibitor adverse effects are intolerable 1
• This patient is tolerating enalapril without documented adverse effects 1

Option D: No Additional Medication

• This is incorrect because the patient is missing essential guideline-directed medical therapy 2, 3
• Delaying initiation of beta-blockers represents a missed opportunity to reduce mortality and morbidity 2, 4

Clinical Stability Confirms Appropriateness

This patient meets all criteria for safe beta-blocker initiation 1:

• Stable clinical status (no signs of congestion: clear chest, no peripheral edema) 1
• Adequate blood pressure (125/83 mmHg) 1
• Acceptable heart rate (76 bpm, not <60 bpm) 1
• No recent exacerbation (follow-up visit, not acute presentation) 1

Beta-blockers should be initiated in the community in stable patients, which describes this clinical scenario 1

Practical Implementation

Starting Beta-Blocker Therapy

• Begin with bisoprolol 1.25 mg once daily 1
• Monitor heart rate, blood pressure, and clinical status after each dose titration 1
• Double the dose every 2 weeks if the preceding dose was well tolerated 1, 2
• Aim for target dose of 10 mg once daily 1
• Continue uptitration even if symptoms improve at lower doses, as clinical trials demonstrated benefits at target doses 2

Patient Education

• Explain that treatment prevents worsening of heart failure and increases survival 1
• Symptomatic improvement may develop slowly over 3-6 months 1
• Temporary symptomatic deterioration may occur in 20-30% of cases during initiation 1
• Advise daily weight monitoring and to report weight gain >1.5-2.0 kg over 2 days 1

Common Pitfalls to Avoid

• Failing to initiate beta-blockers in stable patients due to misconceptions about safety 2, 3
• Underutilization of beta-blockers, especially in older adults 3
• Failing to uptitrate to target doses used in clinical trials 2
• Stopping beta-blockers when clinical improvement occurs 1
• Initiating beta-blockers during acute decompensation or in patients with signs of congestion 1

Monitoring Requirements

• Assess renal function and electrolytes before initiation and periodically thereafter 2
• Check blood chemistry 1-2 weeks after initiation and 1-2 weeks after final dose titration 1
• Monitor for worsening symptoms, bradycardia (<50 bpm), or symptomatic hypotension 1