What intervention improves survival in a 69-year-old female with a history of chronic hypertension, previous myocardial infarction (MI), left ventricular ejection fraction (LVEF) of 32%, and symptoms of heart failure, currently treated with aspirin (acetylsalicylic acid), atorvastatin, Lasix (furosemide), Lisinopril (Lisipril), and Toprol XL (metoprolol succinate)?

From the Guidelines

The intervention that has been shown to improve survival in patients like this is option D, adding eplerenone. This 69-year-old female has heart failure with reduced ejection fraction (HFrEF) as evidenced by her left ventricular ejection fraction of 32% and symptoms of exertional dyspnea. Eplerenone, an aldosterone antagonist, has demonstrated significant mortality benefits in patients with HFrEF, as shown in the EPHESUS trial 1, which reported a 15% reduction in mortality. The patient's current regimen already includes appropriate medications like an ACE inhibitor (lisinopril) and a beta-blocker (toprol XL), but the addition of an aldosterone antagonist would complete the guideline-directed medical therapy triad for HFrEF, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1. Before starting eplerenone, it's essential to monitor the patient's potassium and renal function regularly, as hyperkalemia is a potential side effect, and ensure that the patient has adequate renal function and a normal serum potassium, as cautioned in the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 1. The typical starting dose would be 25 mg daily, which can be titrated based on the patient's response and laboratory values. Some key points to consider when adding eplerenone include:

• Monitoring potassium levels regularly to avoid hyperkalemia
• Ensuring adequate renal function before initiating therapy
• Starting with a low dose and titrating as needed
• Considering the patient's overall clinical status and adjusting the treatment plan accordingly The other options would not provide the same mortality benefit in this clinical scenario. For example, increasing the Lasix dose (option A) may help with symptom management but would not address the underlying pathophysiology of HFrEF. Adding a long-acting nitrate (option B) may also provide symptom relief but would not have the same mortality benefit as eplerenone. Digoxin (option C) can be beneficial in patients with HFrEF, but its use is generally reserved for patients with persistent symptoms despite optimal medical therapy, and it would not provide the same mortality benefit as eplerenone. Corlanor (option E) is an if inhibitor that can be used to reduce hospitalization in patients with HFrEF, but it would not provide the same mortality benefit as eplerenone.

From the FDA Drug Label

In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance. A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose The GISSI-3 study was a multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction (MI) admitted to a coronary care unit Patients receiving lisinopril (n=9,646), alone or with nitrates, had an 11% lower risk of death (p = 0.04) compared to patients who did not receive lisinopril (n=9,672) (6.4% vs. 7. 2%, respectively) at six weeks In a large (1,395 patients randomized), double-blind, placebo-controlled clinical study, metoprolol was shown to reduce 3-month mortality by 36% in patients with suspected or definite myocardial infarction

The patient has a history of chronic hypertension and previous MI, and is currently experiencing heart failure symptoms, with a left ventricular ejection fraction of 32%.

• The most relevant intervention that has been shown to improve survival in patients like this is the addition of an ACE inhibitor, such as lisinopril 2, or a beta-blocker, such as metoprolol 3.
• Option D: adding Eplerenone is not directly supported by the provided drug labels, but lisinopril and metoprolol have been shown to be effective in improving survival in patients with heart failure and myocardial infarction.
• Option E: adding Corlanor is not mentioned in the provided drug labels.
• The best option is to add a beta-blocker, such as metoprolol, which has been shown to reduce 3-month mortality by 36% in patients with suspected or definite myocardial infarction 3.

From the Research

Patient Profile

• 69-year-old female with a history of chronic hypertension and previous MI
• Hospitalized for chest pain six weeks prior, with authorization showing one lesion in the circumflex artery less than 50% occluded
• Current medications include aspirin, atorvastatin, Lasix, Lepri, and Toprol XL
• Echocardiogram shows a left ventricular ejection fraction (LVEF) of 32%
• Patient reports difficulty walking up a single flight of stairs

Treatment Options

• The patient's LVEF of 32% indicates heart failure with reduced ejection fraction (HFrEF) 4, 5, 6, 7
• Treatment options for HFrEF include:
  • Beta-blockers, which the patient is already taking (Toprol XL)
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs)
  • Aldosterone antagonists, such as eplerenone (Inspra) 8
  • Diuretics, such as Lasix, which the patient is already taking
  • Ivabradine, which may be considered for patients with HFrEF and a heart rate >70 bpm 6

Recommended Interventions

• Adding an aldosterone antagonist, such as eplerenone (Inspra), may be beneficial for patients with HFrEF and an LVEF ≤30% 5, 8
• Ivabradine may be considered for patients with HFrEF and a heart rate >70 bpm, although the patient's current heart rate is 55 bpm 6
• Increasing the dose of Lasix may be necessary to manage symptoms of heart failure, but this should be done cautiously to avoid dehydration and electrolyte imbalances
• Adding digoxin may be considered for patients with HFrEF and symptoms of heart failure, but its use is generally reserved for patients who remain symptomatic despite optimal medical therapy 6, 7
• Adding Corlanor (ivabradine) may be considered for patients with HFrEF and a heart rate >70 bpm, although the patient's current heart rate is 55 bpm 6