Cardiorenal Stabilization and Improvement with Sodium-Glucose Cotransporter-2 Inhibition

A 75-year-old Caucasian woman with a 10-year history of type-2 diabetes mellitus, and a 3-year history of ischemic cardiomyopathy following an anterior myocardial infarction presents for office evaluation of class II heart failure symptoms. Her review of systems (ROS) is negative for diabetic ketoacidosis, peripheral artery disease, or genital mycotic infections. Current medications include metformin, sitagliptin, enalapril, and carvedilol. Her blood pressure is 130/85mmHg, pulse 70 beats per minute, and exam notable for a diffuse and laterally displaced point of maximal impulse (PMI), soft S1 S2, no S3 or murmurs, and 1+ pedal edema. An electrocardiogram (ECG) reveals normal sinus rhythm (NSR), left ventricular hypertrophy (LVH), and Q-waves anteriorly. An echocardiogram demonstrates left ventricular ejection fraction (LVEF)=35%, and anterior hypokinesis. Laboratories: Cr=1.7, HbA1C=7.2%, BNP=310 pg/ml, urine albumin/creatinine ratio=410 mg/g.

Which of the following therapeutic changes will reduce this patient's risks for heart failure hospitalization, cardiovascular death, and progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD) or renal death?

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