Systolic Heart Failure

A 58-year-old man is evaluated in the office for a 3-month history of shortness of breath with exertion. He has a 10-year history of hypertension and type 2 diabetes mellitus but no history of coronary artery disease. His medications are extended-release metoprolol, aspirin, metformin, and atorvastatin.

On physical examination, blood pressure is 165/92 mm Hg and heart rate is 88/min. Jugular venous pressure is 10 cm H2O. Bibasilar crackles are present, cardiac rhythm is regular, and an S3 is present. Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy. Laboratory test results include potassium of 4.2 meq/L and creatinine of 1.0 mg/dL. An echocardiogram is ordered, and furosemide is prescribed.

The patient returns the following week with resolution of his symptoms. His blood pressure at this visit is 130/78 mm Hg, his heart rate is 65/min, jugular venous pressure is 4 cm H2O, lungs are clear, and the S3 is absent. The echocardiogram shows left ventricular hypertrophy, reduced systolic function, and inferior wall hypokinesis.

Which of the following is the most appropriate medication change at this time?
A Change metoprolol to carvedilol
B Start digoxin
C Start lisinopril
D Start spironolactone

Key Point
Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.

Answer and Critique (Correct Answer = C)

Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of the level of the ejection fraction or functional status unless there are contraindications (including hyperkalemia, acute renal failure, or a history of angioedema).

Sustained-release metoprolol and carvedilol are both approved for heart failure treatment in the United States. Currently, there is no definitive evidence indicating whether one is better than the other for the treatment of heart failure. Digoxin improves symptoms and reduces hospitalizations for patients with heart failure but is not indicated for patients with asymptomatic heart failure in the absence of other indications (such as rate control for atrial fibrillation). Spironolactone is indicated for patients with heart failure who have severe symptoms (New York Heart Association class III or IV).
Bibliography

1. Dagenais GR, Pogue J, Fox K, Simoons ML, Yusuf S. Angiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet. 2006;368:581-8. [PMID: 16905022]