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The following question refers to Section 6.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by\xa0Dr. Christian Faaborg-Andersen, answered first by Houston Methodist medicine resident\xa0Dr. Najah Khan, and then by expert faculty\xa0Dr. Jaideep Patel.\n\nDr. Patel recently graduated from Virginia Commonwealth University cardiology fellowship and is now a preventive cardiologist at the Johns Hopkins Hospital.\n\nThe CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines\xa0represents a collaboration with the\xa0ACC Prevention of CVD Section, the\xa0National Lipid Association, and\xa0Preventive Cardiovascular Nurses Association.\n\nQuestion #18\n\nA 60-year-old Black woman with a history of hypertension and heart failure with reduced ejection fraction (EF 40%) presents to clinic for follow-up. She is currently doing well with NYHA class II symptoms. She is taking carvedilol 25 mg BID, sacubitril/valsartan 97/103 mg BID, and spironolactone 25 mg daily, all of which have been well tolerated. In clinic, her BP is 125/80 mmHg, and her HR is 55 bpm. Routine labs are within normal limits including Cr of 1.0, K of 4.0, and HbA1c of 6.0. What is the most appropriate next step in her management?\n\nA. No change in management\nB. Reduce beta blocker\nC. Add an SGLT2 inhibitor (dapagliflozin or empagliflozin)\nD. Add vericiguat\nE. Add hydralazine/isosorbide dinitrate\n\nAnswer #18\n\nThe correct answer is C \u2013 Add an SGLT2 inhibitor (dapagliflozin or empagliflozin)\n\nFor patients with symptomatic HFrEF, neurohormonal antagonists (ACEi, ARB, ARNI; BB; MRA) improve survival and reduce the risk of HF hospitalization. This patient is already on these agents. The addition of an SGLT2 inhibitor on top of neurohormonal blockade reduces the risk of CV death and worsening HF in patients with symptomatic HFrEF and is the next best step for this patient (Class I, LOE A).\n\nVericiguat may be considered in patients with symptomatic HFrEF with HF worsening despite already being on maximally tolerated neurohormonal blockade (Class IIb, LOE B), but first-line therapies should be started first.\n\nHydralazine/Isosorbide dinitrate should be considered in self-identified Black patients or people who have EF \u2264 35% or <45% with dilated LV with class III-IV symptoms despite maximally tolerated neurohormonal blockade (Class IIa, LOE B), but is not the next best step here.\n\nShe is tolerating the beta blocker without adverse effects so there is no reason to decrease the dosage.\n\nMain Takeaway\n\nIn patients with symptomatic HFrEF (EF \u2264 40%), SGLT2 inhibitors are considered first line therapy in addition to ACE-I/ARB/ARNI, BB, and MRAs to reduce the risk of HF hospitalization and death. Importantly this is irrespective of presence of diabetes.\n\nGuideline Location\n\nSection 6.2, page 3295-3296\n\nFigure 13 page 3278; recommendation table page 3279.\n\n\n\nCardioNerds Decipher the Guidelines - 2021 ESC Prevention Series\nCardioNerds Episode Page\nCardioNerds Academy\nCardionerds Healy Honor Roll\n\nCardioNerds Journal Club\nSubscribe to The Heartbeat Newsletter!\nCheck out CardioNerds SWAG!\nBecome a CardioNerds Patron!