Reducing Cardiovascular Events in Patients with Heart Failure and Type 2 Diabetes Mellitus

A 65-year-old man with a history of chronic heart failure with reduced ejection fraction (HFrEF) is admitted with exertional shortness of breath, paroxysmal nocturnal dyspnea, bendopnea, and weight gain. At the time of admission, his eGFR is 65 mL/min/1.73 m2 and an N-terminal pro-B-type natriuretic peptide (NT-proBNP) is 1,200 pg/mL.

Prior medical history includes the following:

  • HFrEF:
    • Echocardiogram (6 months prior): left ventricular ejection fraction (LVEF) 25%, normal right ventricular function, and no significant valvular dysfunction.
    • CRT-D implanted 2 years prior for primary prevention and a left bundle branch block with a QRS width > 150 ms.
    • Home medications include carvedilol, spironolactone, and sacubitril/valsartan.
  • Type 2 diabetes mellitus:
    • Most recent HbA1c of 7.4% when measured 3 months ago.
  • Hypertension
  • Stage 2 chronic kidney disease

He is diagnosed with acutely decompensated heart failure and started on IV furosemide. After 3 days of diuresis, his symptoms have markedly improved and his weight has returned to baseline. He is transitioned back to an oral diuretic regimen.

Relevant labs on the day of transition to oral diuretics include:

  • Sodium 134 mEq/L
  • Potassium 4.1 mEq/L
  • eGFR 60 mL/min/1.73 m2

His blood pressure on the day of transition to oral diuretics is 110/70 mmHg, his heart rate is 65 beats per minute, and he required no supplemental oxygen throughout the admission.
Current in-hospital medications:

  • Sacubitril/valsartan 97/103 mg twice daily
  • Carvedilol 25 mg twice daily
  • Spironolactone 25 mg once daily
  • Bumetanide 2 mg once daily
  • Metformin 1,000 mg twice daily

Prior to discharge from the hospital, the addition of which of the following medications to his current regimen would decrease his risk of cardiovascular death and future heart failure hospitalization or urgent visit for heart failure?

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