A 65-year-old man recently recovered from a heart attack is reviewed in clinic. His echocardiogram shows a left ventricular ejection fraction of 35%. He feels well with no breathlessness, his pulse is 76/min regular, and blood pressure is 120/70 mmHg. He is currently taking aspirin, a statin, and an ACE inhibitor. What is the most appropriate additional medication?
a) Start metoprolol
b) Add spironolactone immediately
c) Start bisoprolol
d) Add furosemide
e) No further treatment needed
Answer: c) Start bisoprolol
Detailed Explanation
This patient has heart failure with reduced ejection fraction (HFrEF) (EF < 40%) following myocardial infarction.
Key principle:
All patients with HFrEF should be on mortality-reducing therapy, not just symptom-relieving drugs.
Core guideline-based therapy (NICE + major trials):
- ACE inhibitor (already on lisinopril ✔️)
- Beta-blocker (NOT yet started ❗)
- Mineralocorticoid receptor antagonist (later step)
- SGLT2 inhibitor (modern addition)
👉 The next step here is to add a beta-blocker with proven mortality benefit.
Important point:
Not all beta-blockers are equal in heart failure.
Evidence-based beta-blockers:
- Bisoprolol
- Carvedilol
- Metoprolol succinate (extended-release)
❗ Atenolol and many others do NOT have mortality benefit in HF.
Why not other options?
- Furosemide → only for fluid overload (patient is euvolemic)
- Isosorbide mononitrate → symptom relief only, no mortality benefit
- No changes → incorrect; patient not on full guideline therapy
- Atenolol → no HF mortality benefit
👉 Therefore: Add bisoprolol
Cheat Sheet (Exam-Oriented)
HFrEF (EF < 40%) Core Drugs (“Fantastic Four”)
- ACEi / ARNI
- Beta-blocker (bisoprolol, carvedilol, metoprolol SR)
- MRA (spironolactone/eplerenone)
- SGLT2 inhibitor
Mortality Benefit Drugs
- ACEi ✔
- Beta-blocker ✔
- MRA ✔
- SGLT2i ✔
NO Mortality Benefit
- Loop diuretics (symptom only)
- Nitrates (unless specific indication)
- Digoxin (symptom/AF only)
Beta-blocker Rule
- Only use: bisoprolol / carvedilol / metoprolol SR
- Avoid: atenolol, propranolol
Flashcards
Q1: What EF defines HFrEF?
A: EF < 40%
Explanation: This threshold guides initiation of mortality-reducing therapy.
Q2: Which beta-blockers reduce mortality in HF?
A: Bisoprolol, carvedilol, metoprolol SR
Explanation: Only these have strong RCT evidence.
Q3: Do diuretics improve survival in HF?
A: No
Explanation: They relieve congestion but do not reduce mortality.
Q4: First drug to add after ACE inhibitor in stable HFrEF?
A: Beta-blocker
Explanation: Core guideline sequencing.
Q5: When to add MRA?
A: After ACEi + beta-blocker, if still symptomatic or per guideline
Explanation: Further mortality reduction.
MCQs
1. A patient with EF 32% is on ramipril. Next step?
a) Add atenolol
b) Add bisoprolol
c) Add furosemide
d) Add nitrate
Answer: b) Add bisoprolol
Explanation: Evidence-based beta-blocker required.
2. Which of the following beta-blockers does NOT reduce mortality in HF?
a) Carvedilol
b) Bisoprolol
c) Atenolol
d) Metoprolol SR
Answer: c) Atenolol
Explanation: No HF mortality data.
3. Which drug improves symptoms but NOT survival in HF?
a) ACE inhibitor
b) Beta-blocker
c) Furosemide
d) Spironolactone
Answer: c) Furosemide
Explanation: Symptomatic relief only.
4. Which combination is FIRST-LINE in HFrEF?
a) ACEi + nitrate
b) ACEi + beta-blocker
c) Beta-blocker + diuretic
d) MRA alone
Answer: b) ACEi + beta-blocker
Explanation: Foundation therapy.
5. Which statement is FALSE regarding HFrEF?
a) Beta-blockers reduce mortality
b) Diuretics reduce mortality
c) ACE inhibitors reduce mortality
d) MRAs reduce mortality
Answer: b) Diuretics reduce mortality
Explanation: They do not improve survival.
6. In stable HF, when should beta-blocker be started?
a) Only if tachycardia
b) Only if symptomatic
c) In all patients unless contraindicated
d) Only after MRA
Answer: c) In all patients unless contraindicated
Explanation: Universal indication in HFrEF.
Summary for Quick Exam Revision
Heart failure with reduced ejection fraction requires aggressive mortality-reducing therapy irrespective of symptoms. The foundational drugs include ACE inhibitors and beta-blockers, followed by mineralocorticoid receptor antagonists and SGLT2 inhibitors. Among beta-blockers, only bisoprolol, carvedilol, and metoprolol (sustained release) have proven survival benefit; agents like atenolol should not be used for this purpose. Diuretics such as furosemide are reserved purely for symptom relief in fluid overload and do not improve prognosis. After myocardial infarction with reduced EF, early initiation of a guideline-directed beta-blocker is essential unless contraindicated. Treatment should be introduced gradually to monitor tolerance and adverse effects. Overall, the exam focus is recognizing that therapy in HFrEF is driven by mortality benefit, not just symptom control, and choosing the correct evidence-based drug class is critical.