2. J.T. is a 62-year-old man with a history of CAD (MI 3 years ago), hypertension, depression, chronic renal insufficiency (baseline SCr is 2.8 mg/dL), peripheral arterial disease, osteoarthritis, hypothyroidism, and HF (LVEF of 25%). His medications include aspirin 81 mg/day, simvastatin 40 mg every night, enalapril 5 mg 2 times/day, metoprolol succinate 50 mg/day, furosemide 80 mg 2 times/day, cilostazol 100 mg 2 times/day, acetaminophen 650 mg 4 times/day, sertraline 100 mg/day, and levothyroxine 0.1 mg/day.

3. His vital signs include BP 120/70 mm Hg and HR 72 beats/minute. Laboratory results are within normal limits, except for an SCr of 2.8 mg/dL. Thyroid- stimulating hormone is 2.6 milliunits/L. His HF is stable and considered NYHA class II.

4. Which one of the following is the best approach for maximizing the management of his HF? A. Discontinue metoprolol and begin carvedilol 12.5 mg 2 times/day. B. Increase enalapril to 10 mg 2 times/day. C. Add spironolactone 25 mg/day. D. Add digoxin 0.125 mg/day.

9. Increasing the ACE inhibitor to target doses should be achieved in all patients, if possible. J.T.'s BP of 120/72 mm Hg safely permits increasing the enalapril from 5 mg to 10 mg 2 times/day, making Answer B correct. There is no consensus that carvedilol is preferred over extended-release metoprolol for patients with HF (Answer A). Spironolactone is not appropriate to initiate because J.T.'s HF is not NYHA class III or IV, and his baseline SCr concentration is greater than 2.5 mg/dL (Answer C).

10. Digoxin should be added only in patients who continue to have symptoms or hospitalizations despite optimal therapy with an ACE inhibitor, β-blocker, and diuretic (Answer D). In addition, cilostazol should be discontinued. J.T. has minimal symptoms, and his therapy has opportunities for optimization.

11. Thank You