A 55 year old man with known heart failure and LVEF of 37% is reviewed in the outpatient clinic with breathlessness. He is NYHA class III with no signs of fluid overload on examination. His BP is 110/60 mmHg, and his heart rate is 55 bpm. He is on bisoprolol 5 mg od and ramipril 10 mg od.
His U&E tests reveal:
Which one of the following medications will you chose next?
A mineralocorticoid receptor antagonist (MRA) (spironolactone or epleronone) is the next choice of medication in patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV) established on optimal ACE inhibitor and beta-blocker (BB). An angiotensin receptor blocker (ARB) is an alternative if an MRA is not tolerated. No indication for furosemide as the patient is not fluid overloaded.
An 80 year old woman is admitted with acute pulmonary oedema on a background of progressive shortness of breath with exertional chest pain for 6 months. She has a history of renal impairment with an eGFR of 40 mL/min. She is initially commenced on IV furosemide with good effect. An echocardiogram reveals LVEF 40% with severe aortic stenosis (AS) with an estimated valve area of 0.7 cm2 .
What would you do next?
The patient has severe AS; therefore an ACE inhibitor is contraindicated. Symptoms are probably due to AS and therefore further investigation is needed to assess for AVR. Angina symptoms should be treated with a BB in the interim. CRT-D is not indicated as severe AS needs addressing and EF is not less than 35% (NICE Guidelines).
You review a 60-year-old man with NHYA class II heart failure in clinic. He has LVEF 35%, BP 110/50 mmHg, and heart rate 80 bpm (sinus rhythm). Current medications are bisoprolol 1.25 mg and ramipril 7.5mg.
What medication alteration would you recommend to the GP?
The patient is not on optimal dosage of BB with a heart rate of 80 bpm; therefore titrate BB in the first instance before adding further agents. The target dose of bisoprolol is 10 mg or as close as tolerated. An MRA would be next line if the patient remains in NYHA class II+, followed by ivabradine if the heart rate remains >70 bpm.
A 35 year old man presents to the medical take with acute heart failure. He has a 2 week history of progressive breathlessness. Past medical history includes type II diabetes mellitus. An echocardiogram subsequently shows an EF of 25% with anterior, septal, and lateral wall motion defects. He is stabilized on medication with furosemide, spironolactone, bisoprolol, and ramipril.
What would be your next course of investigation?
The echocardiogram is suggestive of ischaemic heart disease being the aetiology of his symptoms. Angiography is the investigation of choice.
A 65 year old woman with ischaemic cardiomyopathy and LVEF 30% comes for review in the outpatient clinic. She is NYHA class II and has been optimally revascularized. Her current heart failure medications are bisoprolol 10 mg od, ramipril 10 mg od, ivabradine 7.5 mg bd, and spironolactone 25 mg. Her ECG shows sinus rhythm, left bundle branch block (QRS duration 135 ms), left axis deviation, and PR interval 180 ms.
Which one of the following managements would you recommend next?
This is difficult as the 2012 ESC Guidelines and NICE Guidelines differ. The patient remains in NYHA class II despite optimal medication and an ECG shows sinus rhythm and LBBB. The ESC recommends CRT-D in patients in sinus rhythm with a QRS duration of ≥130 ms, LBBB QRS morphology, and an EF ≤30%. If she was in NYHA class III (or class IV with reasonable functionality), then CRT-P/D (defibrillators may be less desirable in advanced HF) is recommended for patients with a QRS ≥120 ms (LBBB) and an EF ≤35%, who are expected to survive with good functional status for >1 year. The ESC does not recommend dyssynchrony echo assessment. Currently NICE recommends CRT for more advanced heart failure (NHYA class III–IV) with EF <35%, and distinguishes the need for a defibrillator based on cardiomyopathy of ischaemic origin. A QRS duration of 120–150 ms requires dyssynchrony on echo. The patient’s age is against transplant.
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