Answer: A. Ivabradine
Although the combination of hydralazine and isosorbide has been shown to improve mortality, particularly in black patients with heart failure already receiving the maximum dose of beta-blockers and angiotensin-converting enzyme inhibitors, this patient’s blood pressure is probably too low to tolerate the addition of these drugs to his regimen. Valsartan is not indicated because the patient is already on lisinopril and the combination of an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker is contraindicated. Spironolactone would be an excellent choice but requires close laboratory follow-up, especially given his borderline potassium level. In addition, he has missed several appointments, and so this may not be the best drug for him.1
Ivabradine inhibits the If current in the sinus node, causing a decrease in heart rate. Although studies have shown reductions in cardiovascular death and heart failure hospitalization, the main effect was a decrease in hospitalizations. Thus, the drug was approved with a class IIa recommendation to reduce heart failure hospitalizations in patients with stable chronic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and symptomatic New York Heart Association class II to III symptoms who are already on the maximum tolerated beta-blocker dose. These patients should be in sinus rhythm with a heart rate ≥70 bpm before initiating this drug.2
- Yancy CW, Jessup M, Bozkurt B, et al; on behalf of the American College of Cardiology Foundation; American Heart Assocation Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Assocation Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-e239.
- Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016;68(13):1476-1488.