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DL, 68, has heart failure with reduced ejection fraction (LVEF 30%), NYHA class II. He takes sacubitril/valsartan 49/51 mg twice daily, bisoprolol 5 mg daily and furosemide 20 mg daily. Potassium is 4.3 mmol/L and eGFR 55 mL/min/1.73 m2. Which addition is most appropriate?
The CCS/CHFS heart failure guidelines recommend four foundational drug classes for HFrEF: an ARNI (or ACEI/ARB), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor, each of which reduces mortality or hospitalization. DL lacks the MRA and SGLT2 inhibitor, and his potassium and eGFR allow both. Non-dihydropyridine CCBs such as diltiazem worsen HFrEF, and digoxin does not reduce mortality. Source: McDonald M et al. CCS/CHFS Heart Failure Guidelines Update: defining a new pharmacologic standard of care for HFrEF (Can J Cardiol 2021;37:531); spironolactone and dapagliflozin product monographs (DPD, checked 2026).
Adding rate-controlling diltiazem in HFrEF.
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