On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Stem
A 68-year-old man with a history of anterior myocardial infarction 3 years ago presents with progressive breathlessness on exertion over 2 months, now unable to walk more than 50 metres, with two-pillow orthopnoea and bilateral ankle swelling. Examination reveals a raised JVP, bilateral basal crackles, and an S3 gallop. Echocardiogram shows LVEF 30%.
Questions
a) What is the diagnosis, and how would you classify his heart failure and functional status? (2 marks)
Diagnosis: heart failure with reduced ejection fraction (HFrEF) — ischaemic cardiomyopathy post-MI, LVEF 30% (≤40% threshold) (1 mark). Functional status: NYHA Class III — marked limitation of physical activity, comfortable only at rest (unable to walk more than 50m without symptoms) (1 mark).[1]
b) List the four pillars of disease-modifying therapy for his HFrEF, with one representative drug and dose for each. (3 marks)
- ARNI or ACE-inhibitor: sacubitril/valsartan target 97/103 mg BD (or enalapril 10-20 mg BD) (0.75 mark)[1]
- Beta-blocker: bisoprolol 10 mg OD or carvedilol 25 mg BD target — started low, uptitrated slowly, and only once euvolaemic (0.75 mark)[1]
- MRA: spironolactone 25-50 mg OD, with potassium and creatinine checked — potassium above 5.5 mmol/L occurred in 11.8 percent on eplerenone versus 7.2 percent on placebo in EMPHASIS-HF (0.75 mark)[1]
- SGLT2 inhibitor: dapagliflozin 10 mg OD or empagliflozin 10 mg OD (0.75 mark) — class 1 in HFrEF, class 2a in HFmrEF and HFpEF[2]
c) He presents 6 weeks later in acute pulmonary oedema with SpO2 88% on room air and BP 145/90 mmHg. Outline his immediate management. (3 marks)
- Sit the patient upright (0.5 mark)[1]
- High-flow oxygen to correct hypoxia (0.5 mark)[1]
- IV furosemide 40-80 mg — the label gives 40 mg slow IV for acute pulmonary oedema, repeated at 80 mg if needed; in DOSE, high-dose diuretics were more effective than low dose without clinically important renal effects (0.5 mark)[3]
- IV nitrates (his BP of 145/90 permits this) (0.5 mark)[1]
- Consider CPAP/non-invasive ventilation for ongoing respiratory distress (0.5 mark)[1]
- Identify and treat any precipitant of this decompensation (non-adherence, arrhythmia, infection, ischaemia) (0.5 mark)[1]
d) List two complications he is at particular risk of, and briefly explain each. (2 marks)
Any two of (1 mark each):
- Ventricular arrhythmia / sudden cardiac death — a leading mode of death in HFrEF; his LVEF of 30% (≤35%) makes him a candidate for primary-prevention ICD once optimally medically managed, on the strength of SCD-HeFT's 23 percent mortality reduction in NYHA II-III with LVEF 35 percent or less[4][2]
- Cardiorenal syndrome — the tension between diuresis for decongestion and preserving renal perfusion; monitor renal function closely
- Atrial fibrillation — common in HF and can itself precipitate decompensation
- Recurrent hospitalisation — his current admission is itself a strong predictor of further admissions and death
References4ShowHide
- [1]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2021.PMID 34447992
- [2]Behnoush AH, Khalaji A, Naderi N, et al. ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison ESC Heart Fail, 2023.PMID 36460629
- [3]Campbell PT, Ryan J. Diuretic dosing in acute decompensated heart failure: lessons from DOSE Curr Heart Fail Rep, 2012.PMID 22699924
- [4]Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure N Engl J Med, 2005.PMID 15659722