A 72-year-old man with a history of chronic heart failure secondary to ischaemic cardiomyopathy is reviewed. He was discharged two weeks ago from hospital following a myocardial infarction. An echocardiogram done during his admission showed a left ventricular ejection fraction of 40% but did not demonstrate any valvular problems. Despite his current treatment with furosemide, ramipril, carvedilol, aspirin and simvastatin he remains short of breath on minimal exertion such as walking 30 metres. On examination his chest is clear and there is minimal peripheral oedema.
What is the most appropriate next step in management?
Correct Answer E: The updated 2010 NICE guidelines now suggest that in addition to aldosterone antagonists both angiotensin-2 receptor blockers and hydralazine in combination with a nitrate are suitable second line treatments for heart failure. However, given that he has had a recent myocardial infarction the best choice is an aldosterone antagonist - please see the NICE guidelines for more details.
Heart failure: drug management:
A number of drugs have been shown to improve mortality in patients with chronic heart failure:
No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.
NICE issued updated guidelines on management in 2010, key points include:
*digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation
**adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
A 76-year-old female is admitted after being found on the floor at her home. On examination she has a core temperature of 30ºC. Her serum electrolytes are within normal range.
Which one of the ECG findings is most likely to be seen?
Correct Answer A:
The following ECG changes may be seen in hypothermia:
A 62-year-old man is reviewed. His blood pressure is poorly controlled at 152/90 mmHg despite treatment with ramipril 10mg od, bendroflumethiazide 2.5mg od and amlodipine 10mg od. In addition to the antihypertensives he also takes aspirin and simvastatin. His most recent blood tests show the following:
What is the most appropriate change to his medication?
Correct Answer C: This patient has reached step 4 in the NICE hypertension guidelines. As their potassium is less than 4.5 mmol/l spironolactone 25mg od should be started.
Hypertension - step 4:
Hypertension: diagnosis and management: NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification: This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension:
If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis. Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment.
Ambulatory blood pressure monitoring (ABPM):
Home blood pressure monitoring (HBPM):
Managing hypertension:
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
Step 4 treatment:
If BP still not controlled seek specialist advice.
New drugs: Direct renin inhibitors
A patient with known heart failure has slight limitation of physical activity. She is comfortable at rest but housework results in fatigue, palpitations or dyspnoea.
What New York Heart Association class best describes severity of their disease?
Correct Answer C:
Heart failure: NYHA classification
The New York Heart Association (NYHA) classification is widely used to classify the severity of heart failure:
NYHA Class I:
NYHA Class II:
NYHA Class III:
NYHA Class IV:
A 51-year-old female presents to the Emergency Department following an episode of transient right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial fibrillation.
If the patient remains in chronic atrial fibrillation what is the most suitable form of anti-coagulation?
Correct Answer B: The CHA2DS2-VASc for this patient is 3 - 2 for the transient ischaemic attack and 1 for being female. She should therefore be offered anti-coagulation with warfarin.
Atrial fibrillation: anti-coagulation
The European Society of Cardiology published updated guidelines on the management of atrial fibrillation in 2012. They suggest using the CHA2DS2-VASc score to determine the most appropriate anti-coagulation strategy.
This scoring system superceded the CHADS2 score.
The table below shows a suggested anti-coagulation strategy* based on the score:
*the wording in the guidelines ('is preferred to') can be slightly confusing. It basically means that, say for a score of 0, whilst aspirin is an acceptable management option the weight of the clinical evidence would support no treatment instead
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