Sun31October0735PM 16

A 67-year-old man is admitted to the coronary care unit with a four-week history of exertional dyspnoea. He is only able to walk 50 metres along the flat before stopping "to catch his breath". He also has a two-week history of orthopnoea and paroxysmal nocturnal dyspnoea. He had coronary artery bypass grafts five years ago following a myocardial infarction. He has no recent history of chest pain.

A transthoracic Doppler 2D echocardiogram shows an ejection fraction of 39% with normal valve function. His current medication includes metoprolol 100 mg, enalapril 10 mg bd, aspirin 75 mg od and furosemide 20 mg. These drugs are well tolerated.

Which of the following is the most appropriate addition to his treatment?

(Please select 1 option)

Commence hydralazine with isosorbide mononitrate

Commence digoxin

Commence losartan

Commence spironolactone This is the correct answer

Institute cardiac resynchronisation therapy with a biventricular pacemaker Incorrect answer selected

Explanation

The National Institute for Health and Clinical Excellence (NICE) produced guidelines in 2010 on the management of chronic heart failure in adults in primary and secondary care.

NICE recommend the first line treatment of ACE inhibitors and beta blockers in heart failure secondary to left ventricular systolic dysfunction.

Those beta blockers licensed for heart failure include:

Bisoprolol

Carvedilol

Metoprolol

Consider an angiotensin receptor blocker (ARB) if a patient is intolerant to ACE inhibitors.

Consider hydralazine in combination with a nitrate if intolerant of ACE inhibitors or ARBs.

If symptoms persist after optimal first-line treatment, specialist advice should be sought and an aldosterone antagonist added as second-line treatment.

If despite optimal second-line treatment the patient's symptoms persist, cardiac resynchronisation therapy or digoxin should be considered.

Answer Statistics

1

6%

2

9%

3

4%

4

71%

5

11%

Times answered: 299