A 58-year-old man with hypertension and a history of myocardial infarction presents with acute decompensated heart failure. Echocardiography shows reduced ejection fraction (EF 28%). He is currently on lisinopril and metoprolol. Which drug should be added as the next-line agent to reduce mortality in systolic heart failure?

Explanation

## Aldosterone Antagonist in Systolic Heart Failure **Key Point:** Spironolactone (an aldosterone antagonist) is the drug of choice for addition to ACE inhibitors and beta-blockers in systolic heart failure (EF ≤35%) because it reduces mortality by 30% in the RALES trial. ### Mechanism of Benefit 1. Blocks aldosterone-mediated sodium and water retention 2. Reduces myocardial fibrosis and remodeling 3. Preserves potassium (unlike loop diuretics) 4. Decreases sudden cardiac death and progressive heart failure mortality ### Evidence Base | Drug Class | Trial | Mortality Reduction | Indication | |---|---|---|---| | ACE inhibitor | CONSENSUS | 27% | All HF stages | | Beta-blocker | CIBIS, MERIT-HF | 34% | All HF stages | | Aldosterone antagonist | RALES | 30% | EF ≤35% + symptoms | | ARB | Val-HeFT | 13% | ACE-I intolerant | **High-Yield:** The "pillars" of HF mortality reduction are: ACE-I/ARB → Beta-blocker → Aldosterone antagonist. This is the evidence-based sequence. **Clinical Pearl:** Spironolactone must be used cautiously in renal impairment (eGFR <30 mL/min) and requires baseline K^+^ and creatinine monitoring due to risk of hyperkalemia. **Tip:** In NEET PG, when a systolic HF patient is already on ACE-I + beta-blocker, the next-line agent is always an aldosterone antagonist, not a calcium channel blocker or vasodilator.