What can be added to the treatment regimen of an adult patient with a known history of heart failure (HF) who is symptomatic despite being on maximum doses of metoprolol (beta-blocker), furosemide (loop diuretic), spironolactone (aldosterone antagonist), and valsartan (angiotensin II receptor blocker)?

Ivabradine Should Be Added

For this symptomatic heart failure patient already on maximum doses of metoprolol, furosemide, spironolactone, and valsartan, ivabradine (Option C) is the correct addition if the patient is in sinus rhythm with heart rate ≥70 bpm. 1

Why Ivabradine is the Answer

• Ivabradine is specifically indicated for persistently symptomatic patients with LVEF ≤35%, in sinus rhythm, with resting heart rate ≥70 bpm despite evidence-based dosing of beta-blocker (or maximally tolerated dose). 1

• The patient is already on maximum-dose metoprolol, making this the exact clinical scenario where ivabradine provides additional benefit by selectively inhibiting the If current in the sinoatrial node for further heart rate reduction. 1

Why the Other Options Are Wrong

Option A: Verapamil - Contraindicated

• Verapamil is contraindicated in systolic heart failure. 1
• Verapamil-type calcium antagonists are only mentioned for diastolic dysfunction or hypertrophic cardiomyopathy, not for systolic heart failure. 1
• Calcium antagonists (except amlodipine) should be avoided in heart failure with reduced systolic function. 2

Option B: Additional Diuretics - Already Optimized

• The patient is already on furosemide (loop diuretic) and spironolactone (potassium-sparing diuretic). 1
• Adding thiazides or metolazone would only be appropriate if there were persistent fluid retention despite current diuretic therapy, which is not specified in this case. 1
• The guidelines recommend combining loop diuretics with thiazides only for insufficient response with persistent fluid retention, not as routine escalation. 1

Option D: Bisoprolol - Redundant

• The patient is already on maximum-dose metoprolol, which is one of the three evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol CR/XL) proven to reduce mortality in heart failure. 1, 3
• Switching from one beta-blocker to another (metoprolol to bisoprolol) provides no additional benefit when already at maximum dose. 3
• Beta-blockers should never be stopped abruptly due to risk of rebound myocardial ischemia/infarction and arrhythmias. 3

Critical Clinical Caveat

Before adding ivabradine, verify the patient is in sinus rhythm with heart rate ≥70 bpm. 1 If the patient has atrial fibrillation or heart rate <70 bpm, ivabradine would not be appropriate. In such cases, consider:

• Digoxin for additional symptom control and reduction in heart failure hospitalizations (though limited mortality benefit). 1, 2
• ARNI (sacubitril/valsartan) as replacement for valsartan if not already tried, though this requires switching the ARB component. 1