A 68-year-old male with a history of anterior myocardial infarction (4 years ago), hypertension, and dyslipidemia is being optimized for heart failure with reduced ejection fraction (HFrEF). He is currently on ramipril 10 mg daily, carvedilol 25 mg twice daily, and spironolactone 25 mg daily. He has persistent NYHA Class III symptoms despite these medications. His eGFR is 45 mL/min/1.73m² and K+ is 4.8 mmol/L. Which of the following is the most appropriate next step?

Question: A 68-year-old male with a history of anterior myocardial infarction (4 years ago), hypertension, and dyslipidemia is being optimized for heart failure with reduced ejection fraction (HFrEF). He is currently on ramipril 10 mg daily, carvedilol 25 mg twice daily, and spironolactone 25 mg daily. He has persistent NYHA Class III symptoms despite these medications. His eGFR is 45 mL/min/1.73m² and K+ is 4.8 mmol/L. Which of the following is the most appropriate next step?

Answer options: ✅ Add sacubitril/valsartan.

• Increase spironolactone to 50 mg daily.
• Add digoxin 0.125 mg daily.
• Discontinue carvedilol due to persistent symptoms.

Correct answer: Add sacubitril/valsartan.

Explanation: For symptomatic HFrEF patients who remain symptomatic despite optimal doses of ACE inhibitor/ARB, beta-blocker, and MRA, switching to an ARNI (sacubitril/valsartan) is a strong recommendation by CCS guidelines to further reduce morbidity and mortality. His renal function and potassium level are within acceptable limits for initiating an ARNI.