A 65-year-old patient with HFrEF (LVEF 30%, NYHA class II) returns to the heart failure clinic. Current medications: sacubitril/valsartan 97/103 mg twice daily, metoprolol succinate 200 mg daily, dapagliflozin 10 mg daily, and furosemide 20 mg daily. Vital signs: BP 112/70 mm Hg, HR 62 beats/minute (sinus rhythm). Labs: K 4.3 mEq/L, SCr 1.1 mg/dL (eGFR 68 mL/min/1.73 m²). Which medication should be added?

Hydralazine/isosorbide dinitrate 37.5/20 mg three times daily

A 70-year-old patient with HFrEF (LVEF 25%, NYHA class III) takes lisinopril 40 mg daily, carvedilol 25 mg twice daily, spironolactone 25 mg daily and dapagliflozin 10 mg daily. BP is 118/70 mm Hg, HR 64 beats/minute (sinus rhythm), K 4.6 mEq/L, eGFR 58 mL/min/1.73 m². The patient has no history of angioedema. Which change is most appropriate?

Switch lisinopril to sacubitril/valsartan after 36 h

Add ivabradine 5 mg twice daily

Add sacubitril/valsartan 24/26 mg; continue lisinopril

A 62-year-old man with HFrEF (LVEF 28%, NYHA class II) takes sacubitril/valsartan 24/26 mg twice daily, metoprolol succinate 200 mg daily, spironolactone 25 mg daily and empagliflozin 10 mg daily. BP is 94/60 mm Hg with dizziness on standing, HR 78 beats/minute in sinus rhythm, K 4.7 mEq/L. Which change should be made to further reduce his risk of HF hospitalization?

Add ivabradine 5 mg twice daily

Add hydralazine/isosorbide dinitrate

Increase metoprolol succinate to 300 mg daily

A 63-year-old woman with HFrEF (LVEF 28%, NYHA class II) takes sacubitril/valsartan 49/51 mg twice daily, carvedilol 12.5 mg twice daily, and empagliflozin 10 mg daily. Today: BP 118/72 mm Hg, K 5.4 mEq/L, eGFR 48 mL/min/1.73 m², NT-proBNP 1,850 pg/mL. The team asks about adding a mineralocorticoid receptor antagonist. Which response is most appropriate?

Do not start an MRA while potassium is 5.0 mEq/L or higher

Start eplerenone 25 mg daily because it causes less hyperkalemia

Start spironolactone 12.5 mg daily as eGFR exceeds 30

Start spironolactone 25 mg daily and stop empagliflozin first

A 64-year-old man hospitalized with newly diagnosed HFrEF (LVEF 25%) is now euvolemic on oral furosemide. BP is 118/74 mm Hg, HR 88 beats/min, K 4.2 mEq/L, and eGFR 60 mL/min/1.73 m². He is on no other HF medications. Which plan before discharge is most appropriate?

Start low-dose ARNI, beta-blocker, MRA, and SGLT2i now

Start carvedilol 25 mg twice daily now, then add an ARNI

Start lisinopril now and add one agent each month in clinic

Defer GDMT until clinic follow-up 4 weeks after discharge

An 84-year-old woman with newly diagnosed HFrEF (LVEF 30%) has BP 102/64 mm Hg with orthostatic lightheadedness, HR 92 beats/min, eGFR 45 mL/min/1.73 m², and K 4.5 mEq/L. She is euvolemic on furosemide 20 mg daily. Which GDMT medication is most appropriate to start first?

Sacubitril/valsartan 49/51 mg twice daily

A 68-year-old man with HFrEF takes sacubitril/valsartan 49/51 mg twice daily, metoprolol succinate, and dapagliflozin. Spironolactone 25 mg daily was started 1 week ago, when K was 4.6 mEq/L and eGFR 52 mL/min/1.73 m². Today K is 5.7 mEq/L and eGFR 49 mL/min/1.73 m²; he has no ECG changes. Which action is most appropriate?

Cut spironolactone to 12.5 mg daily; recheck in 1 week

Stop sacubitril/valsartan and keep spironolactone

Continue spironolactone, since K is still below 6.0

Stop spironolactone permanently and do not rechallenge

BCPS Heart Failure GDMT: The Four Pillars and Start Order

1Survival drugs and symptom drugs

Sort every heart failure drug into one of two columns before you answer anything. The survival column holds the four pillars. The symptom column holds loop diuretics, which clear congestion and are dosed to volume status, and digoxin, which can reduce hospital admissions but has not been shown to lower mortality. Both earn their place on the list, and neither counts toward GDMT.

The trap is that symptom drugs are the ones patients notice. A loop diuretic makes the swelling go down within days; an MRA does nothing the patient can feel. When a case asks what will change the outcome, the drug with the visible effect is usually the distractor.

1.1What the 2022 guideline changed

Older teaching listed an ACE inhibitor, a beta-blocker and, later, an MRA. The 2022 AHA/ACC/HFSA guideline moved the ARNI sacubitril/valsartan to the preferred form of renin-angiotensin inhibition and added SGLT2 inhibitors as a pillar in their own right, with or without diabetes. It also named a category for patients whose ejection fraction recovers, heart failure with improved ejection fraction (HFimpEF), and told clinicians to keep GDMT going in them rather than treat the improved number as a cure.

2The four pillars at a glance

HFrEF pillars per the 2022 AHA/ACC/HFSA guideline and the 2024 ACC Expert Consensus Decision Pathway
Pillar	Agents with outcome data	What to watch
Renin-angiotensin inhibition	Sacubitril/valsartan preferred; an ACE inhibitor or ARB when an ARNI is not possible	Blood pressure, potassium, renal function, angioedema history; the ARNI label forbids overlap with an ACE inhibitor
Beta-blocker	Carvedilol, metoprolol succinate, bisoprolol only	Heart rate, blood pressure, congestion; metoprolol tartrate is not one of the three
MRA	Spironolactone, eplerenone	Potassium and renal function before the first dose and again soon after; the guideline sets the cutoffs
SGLT2 inhibitor	Dapagliflozin, empagliflozin	Volume status (it adds a mild diuretic effect), genital mycotic infection, sick-day rules for ketoacidosis

Target doses come from the trials and are printed in the guideline tables and in each product label.

3Building the regimen in order

Settle the volume
Use a loop diuretic to bring the patient to euvolemia. A beta-blocker is not started into active decompensated congestion.
Start every pillar early, at low doses
The 2024 ACC Expert Consensus Decision Pathway favors getting all four on board within a short window instead of maximizing one drug for months before adding the next. The order is flexible and is chosen from blood pressure, heart rate, potassium and kidney function.
Titrate toward trial doses
Raise doses at short intervals while you watch blood pressure, potassium and creatinine. A small creatinine rise after renin-angiotensin or SGLT2 inhibition is expected, and it is rarely a reason to stop.
Remove what harms
The guideline lists drugs that worsen HFrEF. Non-dihydropyridine calcium channel blockers depress contractility; NSAIDs and thiazolidinediones promote fluid retention. Reconcile the home list at every transition of care.
Reassess the ejection fraction
If the ejection fraction improves, the patient now has HFimpEF and GDMT continues. Stopping it is the classic way to lose the gain.

4Pillar by pillar: practice cases

Each patient is partway through GDMT. Blood pressure, heart rate and potassium decide which pillar fits next, so read them first.

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

Case 1 of 8 · 0 answered

How case rounds work

Pick an option to see the verdict and a note on every option. Keys while the round has focus: 1–5 or A–E answer, ← → move between cases. Nothing is saved or sent anywhere.

Case 01
A 65-year-old patient with HFrEF (LVEF 30%, NYHA class II) returns to the heart failure clinic. Current medications: sacubitril/valsartan 97/103 mg twice daily, metoprolol succinate 200 mg daily, dapagliflozin 10 mg daily, and furosemide 20 mg daily. Vital signs: BP 112/70 mm Hg, HR 62 beats/minute (sinus rhythm). Labs: K 4.3 mEq/L, SCr 1.1 mg/dL (eGFR 68 mL/min/1.73 m²). Which medication should be added?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
The patient is on three of the four Class 1 HFrEF pillars (ARNI, evidence-based β-blocker, SGLT2 inhibitor) but no MRA, and with eGFR above 30 and K below 5.0 mEq/L spironolactone is indicated to reduce mortality and hospitalization. Ivabradine requires a resting HR of at least 70 beats/minute on a maximally tolerated β-blocker, which this patient (HR 62) does not meet. Hydralazine/ISDN is added for self-identified Black patients in NYHA III–IV already on full GDMT, and digoxin (Class 2b) only reduces hospitalization without a mortality benefit.
A
Digoxin only trims HF admissions with no survival gain, and it is held for patients still symptomatic once every pillar is on board.
B
Correct. He already takes an ARNI, a target-dose beta-blocker and an SGLT2 inhibitor; with K 4.3 and eGFR 68 the missing MRA pillar is due.
C
Hydralazine/isosorbide dinitrate is an add-on for self-identified Black patients in NYHA III–IV on full GDMT, not a substitute for a missing MRA.
D
Ivabradine requires a resting sinus rate of 70 or more on a maximally tolerated beta-blocker; his HR is 62.
Case 02
A 70-year-old patient with HFrEF (LVEF 25%, NYHA class III) takes lisinopril 40 mg daily, carvedilol 25 mg twice daily, spironolactone 25 mg daily and dapagliflozin 10 mg daily. BP is 118/70 mm Hg, HR 64 beats/minute (sinus rhythm), K 4.6 mEq/L, eGFR 58 mL/min/1.73 m². The patient has no history of angioedema. Which change is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Replacing the ACE inhibitor with sacubitril/valsartan further reduces mortality and HF hospitalization (PARADIGM-HF, Class 1), and a 36-hour washout after the last lisinopril dose is required to avoid angioedema. Giving both together is the dangerous version of the right idea, because neprilysin inhibition plus ACE inhibition sharply raises angioedema risk. Ivabradine needs a resting HR of at least 70 beats/minute, and digoxin reduces hospitalization only and is reserved for patients still symptomatic on full GDMT.
A
Correct. Moving from the ACE inhibitor to sacubitril/valsartan lowers death and HF admissions, and the 36-hour washout prevents angioedema.
B
Ivabradine needs a sinus rate of at least 70 beats/minute; at 64 he does not qualify.
C
Digoxin reduces admissions only and is a late option; the bigger gain here is replacing the ACE inhibitor with an ARNI.
D
Neprilysin inhibition on top of an ACE inhibitor sharply raises angioedema risk, so the two are never given together.
Case 03
A 62-year-old man with HFrEF (LVEF 28%, NYHA class II) takes sacubitril/valsartan 24/26 mg twice daily, metoprolol succinate 200 mg daily, spironolactone 25 mg daily and empagliflozin 10 mg daily. BP is 94/60 mm Hg with dizziness on standing, HR 78 beats/minute in sinus rhythm, K 4.7 mEq/L. Which change should be made to further reduce his risk of HF hospitalization?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Ivabradine reduces HF hospitalization in symptomatic HFrEF patients in sinus rhythm with HR of at least 70 beats/minute on a maximally tolerated β-blocker (SHIFT), and it lowers HR without lowering BP, which matters at 94/60 mm Hg. Metoprolol succinate 200 mg is already the target dose, so increasing it exceeds the evidence-based maximum and would worsen hypotension. Hydralazine/ISDN would drop his BP further, and digoxin is a weaker (Class 2b) option that reduces hospitalization but needs level monitoring.
A
Correct. Sinus rhythm at 78 on target-dose metoprolol meets the ivabradine criteria, and it slows the heart without lowering his 94/60 BP.
B
This combination is a vasodilator pair that would push an already dizzy, hypotensive patient lower.
C
Metoprolol succinate 200 mg is the target dose; going higher has no supporting evidence and would worsen his hypotension.
D
Digoxin is a weaker add-on that cuts admissions without a survival benefit and needs level monitoring.
Case 04
A 63-year-old woman with HFrEF (LVEF 28%, NYHA class II) takes sacubitril/valsartan 49/51 mg twice daily, carvedilol 12.5 mg twice daily, and empagliflozin 10 mg daily. Today: BP 118/72 mm Hg, K 5.4 mEq/L, eGFR 48 mL/min/1.73 m², NT-proBNP 1,850 pg/mL. The team asks about adding a mineralocorticoid receptor antagonist. Which response is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
Guideline criteria for starting an MRA in HFrEF are eGFR >30 mL/min/1.73 m² and potassium <5.0 mEq/L; with K 5.4 mEq/L the risk of life-threatening hyperkalemia outweighs the benefit until the cause is addressed. A satisfactory eGFR does not offset the elevated potassium, and eplerenone carries a hyperkalemia risk similar enough that the same threshold applies. Stopping the SGLT2 inhibitor removes a mortality-reducing pillar and would not lower potassium.
A
Eplerenone raises potassium too; the same K below 5.0 mEq/L threshold applies to either MRA.
B
An eGFR above 30 is only half of the entry rule; potassium must also be below 5.0 mEq/L, and here it is 5.4.
C
Stopping empagliflozin removes a mortality-reducing pillar and does nothing to bring potassium down.
D
Correct. MRA initiation needs K below 5.0 mEq/L as well as eGFR above 30; at 5.4 the hyperkalemia risk outweighs the benefit for now.
Case 05
A 64-year-old man hospitalized with newly diagnosed HFrEF (LVEF 25%) is now euvolemic on oral furosemide. BP is 118/74 mm Hg, HR 88 beats/min, K 4.2 mEq/L, and eGFR 60 mL/min/1.73 m². He is on no other HF medications. Which plan before discharge is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Current guidance favors starting all four GDMT pillars at low doses during the hospitalization once the patient is stable, then titrating rapidly (STRONG-HF showed fewer deaths and readmissions with this approach); his BP, K, and eGFR allow it. Adding one drug per month is the outdated sequential approach that leaves him unprotected for months, and starting carvedilol at its target dose risks hypotension and worsening HF. Deferring therapy until follow-up loses the window in which post-discharge risk is highest.
A
Carvedilol 25 mg twice daily is a target dose, and starting a beta-blocker there in new HFrEF invites hypotension and decompensation.
B
Correct. With stable BP, K and eGFR, all four pillars can start at low doses before discharge and be titrated quickly afterward.
C
One new drug a month is the old sequential approach, which leaves him under-treated during the riskiest months.
D
The weeks right after discharge carry the highest risk of readmission and death, so putting GDMT off wastes that window.
Case 06
An 84-year-old woman with newly diagnosed HFrEF (LVEF 30%) has BP 102/64 mm Hg with orthostatic lightheadedness, HR 92 beats/min, eGFR 45 mL/min/1.73 m², and K 4.5 mEq/L. She is euvolemic on furosemide 20 mg daily. Which GDMT medication is most appropriate to start first?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
An SGLT2 inhibitor reduces HF hospitalization and death with little effect on BP or potassium, so it is the best first step in a frail patient with borderline BP; other pillars are then added at low doses as tolerated. Sacubitril/valsartan 49/51 mg is above the 24/26 mg starting dose appropriate for low BP and eGFR <60. Carvedilol 25 mg twice daily is a target dose, not a starting dose, and spironolactone 50 mg exceeds the usual 12.5–25 mg start and raises hyperkalemia risk.
A
Carvedilol 25 mg twice daily is a target, not a starting, dose and would deepen her orthostatic hypotension.
B
Correct. An SGLT2 inhibitor cuts HF events with little effect on BP or potassium, a safe first step with a BP of 102/64 and orthostasis.
C
With low BP and an eGFR under 60, an ARNI would start at 24/26 mg, if at all; 49/51 mg risks symptomatic hypotension.
D
MRAs start at 12.5–25 mg daily; 50 mg in an 84-year-old with eGFR 45 is a hyperkalemia setup.
Case 07
A 67-year-old man is being discharged after his first admission for HFrEF (LVEF 30%). New discharge orders include sacubitril/valsartan, metoprolol succinate, spironolactone, dapagliflozin, and furosemide. His home list, verified with his pharmacy, includes diltiazem ER 180 mg daily for hypertension, atorvastatin 40 mg daily, omeprazole 20 mg daily, and tamsulosin 0.4 mg daily. Which home medication should be discontinued?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Non-dihydropyridine calcium channel blockers have negative inotropic effects and are associated with worsening HF in HFrEF, so diltiazem should be stopped—and its BP role is now filled by GDMT. Atorvastatin has no harmful effect in HF and treats his cardiovascular risk. Omeprazole and tamsulosin warrant review for indication and orthostasis, but neither is harmful in HFrEF the way diltiazem is.
A
Atorvastatin is safe in HF and treats his cardiovascular risk, so it stays.
B
Correct. Diltiazem is a non-dihydropyridine calcium channel blocker with negative inotropy that worsens HFrEF, and GDMT now covers his BP.
C
Omeprazole deserves an indication review at some point, but it does not harm the failing ventricle.
D
Tamsulosin is worth watching for orthostasis alongside new GDMT, yet it is not the drug that worsens HFrEF.
Case 08
A 68-year-old man with HFrEF takes sacubitril/valsartan 49/51 mg twice daily, metoprolol succinate, and dapagliflozin. Spironolactone 25 mg daily was started 1 week ago, when K was 4.6 mEq/L and eGFR 52 mL/min/1.73 m². Today K is 5.7 mEq/L and eGFR 49 mL/min/1.73 m²; he has no ECG changes. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
After starting an MRA, potassium and renal function are checked within a week; a K of 5.5–6.0 mEq/L calls for halving the MRA dose (or every-other-day dosing) and close rechecking, whereas K above 6.0 calls for stopping it. Continuing unchanged risks progression to dangerous hyperkalemia. Permanent discontinuation or stopping the ARNI sacrifices a mortality-reducing therapy when a dose reduction is enough.
A
The ARNI is a mortality-reducing pillar; the drug just started and most likely to explain the rise is spironolactone.
B
A K of 5.5–6.0 calls for action now; continuing the same dose lets it climb toward dangerous levels.
C
Correct. With K 5.5–6.0 mEq/L and no ECG changes, the MRA dose is halved and potassium rechecked within about a week.
D
Permanent discontinuation is reserved for K above 6.0 or recurrent problems; a dose cut keeps the survival benefit.

5References

Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation, 2022. Pillars, HFimpEF, drugs that cause harm. As of October 27, 2026.
2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction. JACC, 2024. Initiation and titration sequence. As of October 27, 2026.

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