Skill Checkup: A 71-Year-Old Man With History of Chronic Heart Failure Presents With Dyspnea, Rales, and Ankle Swelling

Marco Guazzi, MD, PhD


May 02, 2022

There are three recommended cornerstone therapies for patients with HFrEF: an angiotensin-converting enzyme (ACE) inhibitor–angiotensin receptor–neprilysin inhibitor (ARNI), a beta-blocker, and a mineralocorticoid receptor antagonist (MRA), unless contraindicated or not tolerated. Of note, the ESC guidelines advise that ARNI may be used as a replacement for ACE inhibitor in patients who remain symptomatic on ACE inhibitor, beta-blocker, and MRA therapies; however, an ARNI may also be considered as a first-line therapy instead of an ACE inhibitor.

In addition to this triad, diuretics are recommended in patients with HFrEF who have symptoms of congestion to improve HF symptoms and exercise capacity while reducing the risk for HF hospitalizations.

The cardiac glycoside digoxin may be added to the standard treatment regimen to reduce the risk for hospitalization in patients with symptomatic HFrEF in sinus rhythm despite treatment with an ACE inhibitor–ARNI, a beta-blocker, and an MRA.

In the present case, after several months of therapy with an ACE inhibitor–ARNI, a beta-blocker, and an MRA, the patient has LVEF of 38% in sinus rhythm, and a resting heart rate of 65 beats/min.


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