For a 75-year-old man with HFrEF on optimal-dose therapy who still has symptoms, what is the best recommendation to improve symptoms and survival?

In patients with heart failure with reduced ejection fraction (HFrEF) who continue to exhibit symptoms despite optimal medical therapy, the introduction of sacubitril/valsartan is a well-supported option. Sacubitril/valsartan, a combination of an angiotensin receptor blocker and a neprilysin inhibitor, has been shown in clinical trials, such as the PARADIGM-HF study, to significantly reduce the risk of cardiovascular death and hospitalization for heart failure compared to traditional therapy with an ACE inhibitor like enalapril.

This medication works by enhancing the levels of natriuretic peptides through neprilysin inhibition, which leads to vasodilation, reduced blood volume, and decreased neurohormonal activation, all contributing to symptom relief and improved heart function in these patients. Therefore, for a patient who is 75 years old, symptomatic, and on optimal therapy, switching from enalapril to sacubitril/valsartan represents the best evidence-based strategy for enhancing both symptoms and survival in heart failure management.