American Board of Family Medicine (ABFM) Practice Exam

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In a patient with congestive heart failure currently on lisinopril and carvedilol, which medication should be added to reduce mortality risk?

  1. Digoxin

  2. Spironolactone

  3. Losartan

  4. Isosorbide dinitrate/hydralazine (BiDil)

The correct answer is: Spironolactone

Adding spironolactone in a patient with congestive heart failure who is already taking lisinopril and carvedilol is beneficial for reducing mortality risk due to its role as an aldosterone antagonist. In heart failure patients, particularly those with reduced ejection fraction, spironolactone has been shown to significantly improve survival rates and reduce hospitalizations related to heart failure. This medication works by blocking the effects of aldosterone, which can lead to sodium retention, increased blood volume, and potassium loss. By mitigating these effects, spironolactone helps to improve the overall hemodynamic profile of the patient, providing additional benefits that complement those of ACE inhibitors like lisinopril and beta-blockers like carvedilol. Other options such as digoxin primarily serve to improve symptoms and may help with heart rate control but do not have the same robust evidence for mortality benefit in heart failure. Losartan, while beneficial in specific populations, does not have the same proven mortality-reducing effect when compared directly to spironolactone. Isosorbide dinitrate/hydralazine (BiDil) is effective, particularly in African American patients with heart failure, but spironolactone remains a cornerstone treatment