In a 55‑year‑old patient with left‑ventricular ejection fraction 36 % (heart failure with reduced EF) and grade I diastolic dysfunction, whose blood pressure is controlled on amlodipine 5 mg daily and losartan 50 mg daily and who is also taking rosuvastatin 20 mg daily and aspirin 80 mg daily, presenting with chest tightness, what medication adjustments or additions should be made?

Medication Management for HFrEF with Chest Tightness

This patient requires immediate initiation of foundational guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction, specifically adding a beta-blocker and an SGLT2 inhibitor, while evaluating and treating the chest tightness as a potential acute coronary syndrome.

Immediate Priorities

1. Evaluate the Chest Tightness First

• Chest tightness in a patient with HFrEF and cardiovascular risk factors requires urgent evaluation for acute coronary syndrome before making medication adjustments 1.
• Obtain troponin, ECG, and consider stress testing or coronary angiography if indicated—this symptom may represent angina requiring revascularization rather than medication adjustment alone 1.
• The current aspirin 80 mg and rosuvastatin 20 mg are appropriate for secondary prevention but insufficient as sole therapy for HFrEF 2, 1.

2. Critical GDMT Gaps to Address

This patient is missing two of the four foundational HFrEF therapies that reduce mortality:

Beta-Blocker (Highest Priority Addition)

• Initiate a beta-blocker immediately (carvedilol, metoprolol succinate, or bisoprolol) as this is a Class I recommendation that reduces mortality and hospitalizations in HFrEF 3, 4, 1, 5.
• Start at low dose (e.g., carvedilol 3.125 mg twice daily or metoprolol succinate 12.5-25 mg daily) and uptitrate every 1-2 weeks to target doses 3, 5.
• Selective β₁ receptor blockers may be preferred as they have less blood pressure-lowering effect than non-selective agents, which is relevant given this patient is already on two antihypertensives 3.
• The beta-blocker provides additional anti-ischemic benefit for the chest tightness if angina is confirmed 4.

SGLT2 Inhibitor (Second Priority Addition)

• Add an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) as this class significantly reduces cardiovascular and all-cause mortality regardless of diabetes status 1, 5, 6.
• SGLT2 inhibitors do not lower blood pressure significantly, making them ideal to start early even in patients on multiple antihypertensives 3.
• This should be initiated alongside or shortly after the beta-blocker 5, 7.

Mineralocorticoid Receptor Antagonist (Third Priority)

• Add spironolactone 12.5-25 mg daily or eplerenone 25 mg daily once beta-blocker and SGLT2 inhibitor are initiated 1, 5.
• Monitor potassium and renal function closely, especially given concurrent losartan use 5.

Optimizing Current Medications

Renin-Angiotensin System Blockade

• The current losartan 50 mg daily is suboptimal—this patient should be transitioned to sacubitril/valsartan (ARNI) once stabilized on other GDMT 3, 1, 6, 8.
• Sacubitril/valsartan reduces mortality and hospitalizations more effectively than ACE inhibitors or ARBs alone 6, 8.
• Start at 24/26 mg or 49/51 mg twice daily (depending on blood pressure tolerance) after a 36-hour washout from losartan 3, 6.
• If blood pressure is a concern, initiate at the lowest dose (24/26 mg twice daily) and uptitrate gradually 3.

Calcium Channel Blocker Consideration

• Amlodipine 5 mg may need to be reduced or discontinued once GDMT is optimized, as blood pressure may decrease with beta-blocker and sacubitril/valsartan initiation 3, 9.
• Amlodipine is not a disease-modifying therapy for HFrEF and should be deprioritized in favor of GDMT 3, 1.
• Monitor blood pressure closely—if systolic BP drops below 90-100 mmHg with symptoms, reduce amlodipine first before adjusting GDMT 3.

Statin and Antiplatelet Therapy

• Continue rosuvastatin 20 mg and aspirin 80 mg as appropriate for cardiovascular risk reduction 2.
• No adjustment needed unless chest tightness evaluation reveals need for dual antiplatelet therapy post-revascularization 2.

Practical Implementation Algorithm

Week 1-2:

1. Evaluate chest tightness urgently (troponin, ECG, stress test/angiography as indicated)
2. Initiate beta-blocker at low dose (e.g., carvedilol 3.125 mg BID)
3. Initiate SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily)
4. Continue losartan 50 mg, amlodipine 5 mg, rosuvastatin 20 mg, aspirin 80 mg

Week 3-4:

1. Uptitrate beta-blocker (e.g., carvedilol to 6.25 mg BID)
2. Add MRA (spironolactone 12.5-25 mg daily)
3. Monitor BP, HR, potassium, creatinine

Week 5-8:

1. Continue beta-blocker uptitration toward target (carvedilol 25 mg BID or metoprolol succinate 200 mg daily)
2. If BP remains >100 mmHg systolic and patient tolerates, transition losartan to sacubitril/valsartan 24/26 mg or 49/51 mg BID after 36-hour washout
3. Consider reducing or stopping amlodipine if BP <100 mmHg or symptomatic hypotension occurs

Week 9-12:

1. Uptitrate sacubitril/valsartan to target dose (97/103 mg BID)
2. Uptitrate MRA if tolerated (spironolactone up to 50 mg daily)
3. Reassess symptoms, functional capacity, and consider repeat echocardiogram at 3-6 months

Critical Monitoring Parameters

• Blood pressure: Target systolic >90 mmHg; asymptomatic low BP (even <90 mmHg) is acceptable if patient tolerates GDMT 3.
• Heart rate: Target 50-60 bpm with beta-blocker; if HR remains >70 bpm despite maximally tolerated beta-blocker, consider adding ivabradine 3, 4.
• Potassium: Monitor closely with dual RAAS blockade (losartan/sacubitril-valsartan + MRA); keep K+ <5.5 mEq/L 5.
• Renal function: Monitor creatinine and eGFR; mild worsening (up to 30% increase in creatinine) is acceptable if not accompanied by hyperkalemia 5.

Common Pitfalls to Avoid

• Do not delay GDMT initiation due to "normal" blood pressure—these medications reduce mortality independent of BP effects 3, 1.
• Do not uptitrate one drug to maximum before starting others—initiate all four foundational classes early and uptitrate gradually in parallel 3, 5.
• Do not discontinue GDMT for asymptomatic hypotension—only symptomatic hypotension (dizziness, presyncope) warrants dose reduction, and even then, reduce non-GDMT medications first (amlodipine) 3.
• Do not overlook the chest tightness—this requires evaluation for ischemia before attributing symptoms solely to heart failure 1.
• Do not use ACE inhibitor + ARB combinations—transition directly to sacubitril/valsartan instead 6.