A patient with heart failure and reduced ejection fraction (LVEF ≤ 35%) should be started on which medication as indicated by the data?

A patient with heart failure and reduced ejection fraction (LVEF ≤ 35%) should be started on which medication as indicated by the data?

• A. Lisinopril
• B. Spironolactone
• C. Furosemide
• D. Metoprolol

Answer: (B)

In heart failure with reduced ejection fraction, adding an aldosterone antagonist to standard therapy has a proven survival benefit when the EF is severely reduced (≤35%). Spironolactone, studied in the RALES trial, reduced both mortality and HF hospitalizations in patients with NYHA class III–IV symptoms and LVEF ≤35% who were already on conventional therapy. The benefit comes from blocking aldosterone’s effects that promote myocardial remodeling, sodium and water retention, and fibrosis, which worsen outcomes in severe systolic HF. Because this patient’s EF is ≤35%, spironolactone is the medication with demonstrated mortality benefit in this data set. Do monitor kidney function and potassium after starting, since spironolactone can cause hyperkalemia, especially if combined with an ACE inhibitor or ARB. It’s a key addition when aiming to improve survival in this EF range, whereas diuretics like furosemide mainly alleviate symptoms, and ACE inhibitors or beta-blockers are foundational but the specific mortality-advancing data in this EF threshold are most clearly demonstrated with spironolactone.

In heart failure with reduced ejection fraction, adding an aldosterone antagonist to standard therapy has a proven survival benefit when the EF is severely reduced (≤35%). Spironolactone, studied in the RALES trial, reduced both mortality and HF hospitalizations in patients with NYHA class III–IV symptoms and LVEF ≤35% who were already on conventional therapy. The benefit comes from blocking aldosterone’s effects that promote myocardial remodeling, sodium and water retention, and fibrosis, which worsen outcomes in severe systolic HF.

Because this patient’s EF is ≤35%, spironolactone is the medication with demonstrated mortality benefit in this data set. Do monitor kidney function and potassium after starting, since spironolactone can cause hyperkalemia, especially if combined with an ACE inhibitor or ARB. It’s a key addition when aiming to improve survival in this EF range, whereas diuretics like furosemide mainly alleviate symptoms, and ACE inhibitors or beta-blockers are foundational but the specific mortality-advancing data in this EF threshold are most clearly demonstrated with spironolactone.