SGLT2 Inhibitors in HFrEF

A 60-year-old man with stable ischemic heart disease, type 2 diabetes, hypertension, hyperlipidemia, and chronic kidney disease presents to the cardiology office after a recent hospitalization for a heart failure (HF) exacerbation. He has a long-standing history of coronary artery disease with 2 prior myocardial infarctions, both requiring percutaneous revascularization 15 and 10 years ago, respectively. At baseline, he has New York Heart Association (NYHA) functional Class II symptoms. He occasionally becomes lightheaded with sudden standing. He has a cardiac resynchronization therapy with defibrillator device with resultant right bundle branch block pattern and QRS duration of 125 msec on electrocardiography. He has had 3 hospitalizations in the past year for HF. His medications include metoprolol succinate 100 mg daily, sacubitril-valsartan 49-51 mg twice daily, eplerenone 25 mg daily, aspirin 81 mg daily, atorvastatin 80 mg daily, sitagliptin-metformin 50-500 mg twice daily, and insulin glargine 30 units nightly. On physical exam, his peripheral pulse is 62 bpm, blood pressure is 95/60 mmHg, there is no jugular venous distension, his lungs are clear to auscultation, and he has no peripheral edema. His laboratory evaluation includes estimated glomerular filtration rate 45 mL/min/1.73m2, low-density lipoprotein 50 mg/dL, N-terminal pro-B-type natriuretic peptide 252 pg/mL, and Hgb A1c 7.8%. Echocardiography shows a left ventricular ejection fraction of 30% and a mildly dilated left ventricle.

Which of the following is the next best step in the management of this patient to reduce his risk for future major adverse cardiovascular events (MACE) and HF hospitalizations?

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