A 64-year-old man presents to the cardiology clinic for follow-up. Three months ago, he was hospitalized for an anterior ST-elevation myocardial infarction and underwent successful percutaneous coronary intervention. Since discharge, he has experienced progressive exertional dyspnea and fatigue. He can walk only one block before needing to stop and rest. His medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include aspirin, atorvastatin, lisinopril, metoprolol succinate, and furosemide. He reports excellent medication adherence. Temperature is 36.8°C (98.2°F), blood pressure is 118/72 mm Hg, pulse is 68/min, and respiratory rate is 16/min. Oxygen saturation is 98% on room air. Physical examination demonstrates mild bibasilar crackles and trace bilateral lower-extremity edema. Jugular venous pressure is mildly elevated.
Laboratory studies show the following:
Sodium: 138 mEq/L
Potassium: 4.4 mEq/L
Creatinine: 1.0 mg/dL
Hemoglobin A1c: 7.1%
Transthoracic echocardiography demonstrates a left ventricular ejection fraction of 30%.
Which of the following medications should be added to this patient’s regimen to reduce mortality and risk of heart failure hospitalization?
The correct answer is:
C) Empagliflozin
This patient has symptomatic heart failure with reduced ejection fraction (HFrEF) following an ischemic cardiomyopathy. Despite receiving an ACE inhibitor, evidence-based beta blocker, and diuretic therapy, he remains symptomatic and has a markedly reduced ejection fraction.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors such as empagliflozin and dapagliflozin have emerged as a foundational component of guideline-directed medical therapy for HFrEF. Large randomized trials demonstrated reductions in cardiovascular death, heart failure hospitalization, and symptom burden in patients with HFrEF regardless of whether they have diabetes.
A high-yield Step 2 concept is distinguishing medications that improve symptoms from those that improve survival. SGLT2 inhibitors, ACE inhibitors (or ARNI therapy), evidence-based beta blockers, and mineralocorticoid receptor antagonists all improve long-term outcomes in HFrEF.
This patient has preserved renal function, stable blood pressure, and no contraindication to SGLT2 inhibitor therapy, making empagliflozin an appropriate addition.
Answer choice A: Digoxin, is incorrect.
Digoxin may improve symptoms and decrease heart failure hospitalizations in selected patients with HFrEF, particularly those with concomitant atrial fibrillation. However, it has not been shown to reduce mortality. When board questions ask specifically about improving survival, other guideline-directed therapies should be prioritized.
Answer choice B: Diltiazem, is incorrect.
Non-dihydropyridine calcium channel blockers can exert negative inotropic effects and may worsen systolic heart failure. They are not part of guideline-directed therapy for HFrEF and do not improve mortality.
Answer choice D: Hydrochlorothiazide, is incorrect.
Thiazide diuretics may assist with blood pressure control or mild volume management but do not reduce mortality in HFrEF. Diuretics improve symptoms by reducing congestion but do not alter disease progression.
Answer choice E: Verapamil, is incorrect.
Like diltiazem, verapamil is a non-dihydropyridine calcium channel blocker with negative inotropic properties. It may worsen systolic dysfunction and should generally be avoided in patients with significantly reduced ejection fraction.
Key Learning Point
Modern guideline-directed medical therapy for HFrEF includes SGLT2 inhibitors, which reduce cardiovascular mortality and heart failure hospitalizations regardless of diabetes status. Students should distinguish therapies that improve survival from those that provide symptomatic benefit alone.
