A 70-year-old patient with heart failure and reduced ejection fraction remains symptomatic on ramipril and bisoprolol. Which medication is most appropriate to add for symptom relief?

• A. Spironolactone
• B. Digoxin
• C. Furosemide
• D. Amlodipine

Answer: (A)

In this scenario, the key idea is that for heart failure with reduced ejection fraction, adding a mineralocorticoid receptor antagonist after optimizing an ACE inhibitor and a beta-blocker provides extra symptom relief and improves outcomes. Spironolactone blocks aldosterone, reducing sodium and water retention and dampening fibrosis and adverse remodeling of the heart. This translates into better symptoms and fewer hospitalizations, as shown in large trials. However, it requires monitoring of potassium and kidney function because of the risk of hyperkalemia, especially when combined with an ACE inhibitor like ramipril.

Digoxin can help some patients with persistent symptoms, but it does not improve survival and is not the primary next step when targeted symptom relief and outcome benefit are the goals. Loop diuretics such as furosemide relieve edema and provide immediate symptom relief but do not confer mortality benefits, so they’re typically used for decongestion rather than as the principal therapy to add after ACE inhibition and beta-blockade. Amlodipine is not indicated for symptom management in HFrEF and can worsen outcomes in this setting.