Brazil Healthcare Practice Test & Exam Prep

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A 62-year-old male with ischemic cardiomyopathy and NYHA Class III heart failure has a left ventricular ejection fraction (LVEF) of 28% despite optimized treatment with enalapril 20 mg BID, carvedilol 25 mg BID, and spironolactone 25 mg daily. His blood pressure is 118/74 mmHg, heart rate is 68 bpm (sinus rhythm), serum potassium is 4.4 mEq/L, and eGFR is 58 mL/min/1.73 m². According to the Diretriz Brasileira de Insuficiência Cardíaca (SBC), what is the most appropriate next step in disease-modifying therapy?

Switch enalapril to sacubitril/valsartan (with a 36-hour washout period) and add an SGLT2 inhibitor (dapagliflozin or empagliflozin). Discontinue carvedilol and initiate ivabradine, while maintaining enalapril and spironolactone. Add digoxin 0.25 mg daily and increase spironolactone to 50 mg daily without changing enalapril. Add amlodipine 10 mg daily to achieve afterload reduction and lower neurohormonal activation.

Correct Answer:

Switch enalapril to sacubitril/valsartan (with a 36-hour washout period) and add an SGLT2 inhibitor (dapagliflozin or empagliflozin).

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