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A 65-year-old man comes to the cardiology clinic for a routine follow-up of heart failure with reduced ejection fraction (HFrEF). His most recent echocardiogram showed a left ventricular ejection fraction of 30%. He is currently taking sacubitril/valsartan and metoprolol succinate. He reports mild dyspnea when walking up a flight of stairs (NYHA class II). His blood pressure is 118/75 mmHg and his heart rate is 65 bpm in normal sinus rhythm. Laboratory results show a serum creatinine of 1.2 mg/dL, serum potassium of 5.3 mEq/L, and an estimated glomerular filtration rate (eGFR) of 65 mL/min/1.73 m2. Which of the following is the most appropriate medication to add to this patient's regimen to further reduce mortality?
- Source
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — Section 7.3. Pharmacological Treatment for HFrEF
- Checked
- Read against this source on 7 Aug 2026. If the guidance changes, the question comes back for another read before it is shown again.
Where this answer comes from
TAKEAWAY
Dapagliflozin, an SGLT2 inhibitor, reduces mortality and hospitalizations in HFrEF and is safe to start here with an eGFR above 30, regardless of diabetes status.
Why D is right
Dapagliflozin is an SGLT2 inhibitor that reduces mortality and hospitalizations in patients with HFrEF. It is one of the four foundational therapies and is safe to initiate in this patient with an eGFR above 30 mL/min, regardless of diabetes status.
Ivabradine is indicated for HFrEF patients with a resting heart rate of 70 bpm or more in sinus rhythm despite maximally tolerated beta-blocker therapy. This patient's heart rate is 65 bpm, so it is not indicated.
While mineralocorticoid receptor antagonists (MRAs) like spironolactone are foundational therapies for HFrEF, they are contraindicated for initiation if the serum potassium is above 5.0 mEq/L due to the risk of life-threatening hyperkalemia.
Digoxin may reduce hospitalizations and improve symptoms in HFrEF but does not have a proven mortality benefit. A mortality-reducing medication (like an SGLT2 inhibitor) should be prioritized.
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Still working out what the exam involves? Our SMLE exam guide covers the format, eligibility, scoring and how to prepare, sourced from the SCFHS applicant guide.
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Read the full SMLE guide for the format, scoring and attempt rules.
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Single best answer vignettes set in local practice, every answer citing its source.
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