. A 57-year-old woman with known heart failure and EF 42% is reviewed in clinic. She is breathless on walking up one flight of stairs or half a mile on the flat. On examination, her BP is 130/90 mmHg and her heart rate is 75 bpm (SR, ECG QRS < 120 ms). Her chest is clear to auscultation. There are no signs of fluid overload.
Her current medication:
Her recent renal function tests are:
She has not previously tolerated an ACE inhibitor or spironolactone because of deteriorating renal function and hyperkalaemia.
What would you do next?
A. Add hydralazine and isosorbide dinitrate (H-ISDN)An ACE inhibitor should only be used in patients with adequate renal function (creatinine ≤221 mmol/L or ≤2.5 mg/dL or eGFR ≥30 mL/min/1.73 m2 ) and a normal serum potassium level. Candesartan and epleronone are also contraindicated in view of the renal function. Furosemide is not indicated because of fluid status. Ivabradine requires an EF <35%. H-ISDN is an alternative to ACE inhibitor/ARB when they are not tolerated, or can be considered in patients on maximal therapy and residual NYHA class II–IV symptoms and EF ≥35%.