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A 65-year-old man comes to the cardiology clinic for a routine follow-up of heart failure with reduced ejection fraction (HFrEF). His most recent echocardiogram showed a left ventricular ejection fraction of 30%. He is currently taking sacubitril/valsartan and metoprolol succinate. He reports mild dyspnea when walking up a flight of stairs (NYHA class II). His blood pressure is 118/75 mmHg and his heart rate is 65 bpm in normal sinus rhythm. Laboratory results show a serum creatinine of 1.2 mg/dL, serum potassium of 5.3 mEq/L, and an estimated glomerular filtration rate (eGFR) of 65 mL/min/1.73 m2. Which of the following is the most appropriate medication to add to this patient's regimen to further reduce mortality?
- Source
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure · Section 7.3. Pharmacological Treatment for HFrEF
- Checked
- Checked against this source on 7 Aug 2026. If the source changes, this question is automatically flagged for re-review.
- Verification
- Two independent AI models answered this question separately and agreed, and every distractor explanation was checked, before a physician approved it for publication.
How this answer is verified
Why D is right
Dapagliflozin is an SGLT2 inhibitor that reduces mortality and hospitalizations in patients with HFrEF. It is one of the four foundational therapies and is safe to initiate in this patient with an eGFR above 30 mL/min, regardless of diabetes status.
Ivabradine is indicated for HFrEF patients with a resting heart rate of 70 bpm or more in sinus rhythm despite maximally tolerated beta-blocker therapy. This patient's heart rate is 65 bpm, so it is not indicated.
While mineralocorticoid receptor antagonists (MRAs) like spironolactone are foundational therapies for HFrEF, they are contraindicated for initiation if the serum potassium is above 5.0 mEq/L due to the risk of life-threatening hyperkalemia.
Digoxin may reduce hospitalizations and improve symptoms in HFrEF but does not have a proven mortality benefit. A mortality-reducing medication (like an SGLT2 inhibitor) should be prioritized.
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Two models must agree
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A physician signs off
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The source stays attached
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A counter we do not pad
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21
published questions
2,674
verified by both models, queued for physician sign-off
as of 10 August 2026
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What happens when a guideline changes?
Every question stores its source and the date it was checked. When the source changes, the question is automatically flagged and re-reviewed rather than silently left stale.
Is there Arabic?
Yes. SMLE questions carry full Arabic text with a per question toggle, so you can read the stem the way you will recall it.
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