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?

Question

Accepted Answer

D. Spironolactone. ## 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.

Answer

A. Amlodipine

Answer

B. Hydralazine

Answer

C. Diltiazem

Explanation

Aldosterone Antagonist in Systolic Heart Failure

Mechanism of Benefit

Evidence Base

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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