Patient Management

Image of John Barker

John Barker
56, Male

The working diagnosis of heart failure with reduced ejection fraction (HFrEF) is confirmed by the elevated plasma BNP, abnormal ECG and echocardiography demonstrating severely impaired left ventricular systolic function (LVEF 32%). John’s past medical history and cardiac MRI findings of prior extensive anterior myocardial infarction are consistent with an underlying aetiology of ischaemic heart disease.

The goals of treatment in patients with heart failure are: to improve clinical status, functional capacity and quality of life, reduce hospital readmission and reduce mortality.

  • You start the following treatments:

    Neurohormonal antagonists (ACEIs, β-blockers and MRAs) have been shown to improve survival in patients with heart failure (HFrEF):

    1. 1. Angiotensin-converting-enzyme inhibitor (ACEI): Ramipril 1.25mg OD (uptitration over several weeks)*. Counteract the deleterious effects of the renin-angiotensin-aldosterone system and reduce ‘adverse remodelling’.
    2. 2. β-blocker: Bisoprolol 1.25mg OD (uptitration over several weeks)*. Counteract sympathetic nervous system activation. May reduce tachyarrhythmias and myocardial ischaemia.
    3. 3. Mineralocorticoid/aldosterone receptor antagonist: Eplerenone 25 mg OD. Counteract the deleterious effects of aldosterone and reduce ‘adverse remodelling’.
    * Uptitration to the maximum tolerated dose for ACEI and β-blocker requires monitoring of blood pressure, heart rate and renal function.

     

    Diuretics are recommended to reduce signs and symptoms in patients with heart failure (HFrEF). Loop diuretics have stronger diuretic effect than thiazide diuretics (although when combined they are synergistic):

    1. 4. Diuretic: Frusemide 40mg OD (with a view to monitoring clinical response and adjusting dose as required).

  • There are other considerations specific to John’s initial investigation results:

    Diabetes:

    1. 5. Glycaemic control should be implemented gradually and moderately with a preference to safe effective drugs such as metformin.

    Signs and investigations suggest familial hypercholesterolaemia:

    1. 6. John’s cholesterol will require treatment with a statin. His target LDL cholesterol concentration should be < 2.0 mmol/L. His children and other first degree relatives should also be investigated.

  • Patient education and lifestyle measures:

    John has been diagnosed with heart failure which is a lifelong chronic condition. Patient education and lifestyle measures are important. Consider the question below as to the key topics that would be relevant in this case: