A 55 Year Old Man With Known Heart Failure Comes For A Review In OPD

A 55-year-old man with known heart failure and LVEF of 37% is reviewed in the outpatient clinic with breathlessness. He is NYHA class III with no signs of fluid overload on examination. His BP is 110/60 mmHg, and his heart rate is 55 bpm. He is on bisoprolol 5 mg od and ramipril 10 mg od.
His U&E tests reveal Na 137 mmol/L, K 4.5 mmol/L, urea 7 mmol/L, and creatinine 85 μmol/L.
Which one of the following medications will you chose next?
A. Furosemide 40 mg od
B. Spironolactone 25 mg od
C. Digoxin 62.5 micrograms od
D. Hydralazine 37.5 mg and isosorbide dinitrate 20 mg od
E. Candesartan 4 mg od

Answer:
B. Spironolactone 25 mg od

Discussion: A mineralocorticoid receptor antagonist (MRA) (spironolactone or epleronone) is the next choice of medication in patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV) established on optimal ACE inhibitor and beta-blocker (BB). An angiotensin receptor blocker (ARB) is an alternative if an MRA is not tolerated. No indication for furosemide as the patient is not fluid overloaded.