American Board of Internal Medicine (ABIM) Certification Practice Exam

In heart failure with reduced ejection fraction, what is associated with a reduction in cardiovascular death and hospitalization?

1. Increased prescription of diuretics

2. Titration of β-blockers before starting ivabradine

3. Use of digoxin

4. Regular exercise

The correct answer is: Titration of β-blockers before starting ivabradine

In the context of heart failure with reduced ejection fraction (HFrEF), the titration of β-blockers before starting ivabradine is associated with a reduction in cardiovascular death and hospitalization. β-blockers have been shown to improve outcomes in patients with heart failure by reducing the heart rate, decreasing myocardial oxygen demand, and improving left ventricular function. Proper titration of β-blockers is critical to achieve their full benefit. It allows the patient to tolerate these medications at optimal doses, which can lead to significant improvements in heart failure symptoms and a reduction in the incidence of hospitalizations and cardiovascular mortality. Before considering other medications such as ivabradine, which is used specifically when heart rates are persistently elevated, it is essential that the heart failure management is first optimized with evidence-based therapies like β-blockers. This ensures that the patient is on an appropriate treatment path that maximizes the potential for improved outcomes. The other options, while relevant to heart failure management, do not provide the same level of evidence for reducing mortality and hospitalizations in the specific context of HFrEF as the titration of β-blockers does.