A 57-Year-Old Man With Heart Failure and Recurrent Hospitalizations

congestive heart failure
congestive heart failure
A 57-year-old black man with ischemic cardiomyopathy presents with low blood pressure and dyspnea on exertion.


A 57-year-old black man with ischemic cardiomyopathy presents for follow-up after coronary artery bypass grafting surgery. He has missed several appointments in the past 2 years. His ejection fraction has been stable at approximately 25% to 30%. He has had 2 hospital admissions for congestive heart failure in the past 6 months. Electrocardiogram in the office shows normal sinus rhythm at a rate of 96 bpm and inferior Q waves.

His current medications include metoprolol XL 150 mg/d, lisinopril 10 mg/d, aspirin 81 mg/d, furosemide 40 mg/d, and atorvastatin 40 mg/d. Laboratory results reveal potassium of 4.9 mEq/L and serum creatinine of 1.2 mg/dL. His heart rate is 94 bpm and blood pressure is 96/58 mm Hg. He reports dyspnea when walking 2 blocks, but feels well at home with his daily activities.

Which of the following medications would be a reasonable addition to his therapy?

A. Ivabradine

B. Spironolactone

C. Valsartan

D. Hydralazine and isosorbide