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A 50-year-old asymptomatic man is evaluated during a routine follow-up visit for heart failure, which was diagnosed 1 year ago. A stress test at the time of diagnosis was negative for ischemia. At his most recent evaluation 4 months ago, echocardiography showed left ventricular enlargement and hypertrophy, left ventricular ejection fraction of 40%, and no significant valvular disease. A 12-lead electrocardiogram was unchanged, showing left ventricular hypertrophy but no evidence of previous myocardial infarction. His current medications include hydrochlorothiazide and lisinopril.

On physical examination, heart rate is 85/min and blood pressure is 135/85 mm Hg. There is no jugular venous distention or peripheral edema. There is a soft S4 but no murmur, and the lungs are clear.

Which of the following medications should be added to the patient's regimen?

A Losartan
B Diltiazem
C Carvedilol
D Spironolactone
E Digoxin

C Carvedilol

Carvedilol

C.

Correct answer is C.
Treatment with an angiotensin-converting enzyme (ACE) inhibitor and a β-blocker is indicated for patients with all degrees of systolic heart failure, including asymptomatic patients, because treatment with both agents has been shown to reduce morbidity and mortality.

Losartan, an angiotensin-receptor blocker (ARB), is an acceptable substitute in a patient who cannot tolerate an ACE inhibitor, but there is no benefit to adding an ARB to an ACE inhibitor. Calcium-channel blockers are indicated in heart failure for the management of hypertension or angina not adequately controlled with an ACE inhibitor or β-blocker. Early generation calcium-channel blockers, such as nifedipine, diltiazem, and verapamil, cause a reactive increase in sympathetic activity in response to peripheral vasodilation and negative inotropic effects, whereas second-generation calcium-channel blockers, such as amlodipine, are more vasoselective, less cardiodepressant, and do not appear to have a deleterious effect on outcome in patients with heart failure. Spironolactone and digoxin are not indicated for asymptomatic systolic heart failure. Spironolactone reduces mortality in patients with severe symptomatic heart failure (New York Heart Association class III or IV) and left ventricular ejection fraction ≤35%. Digoxin alleviates symptoms and reduces hospitalizations related to heart failure, but has not been shown to reduce mortality.

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