John returns for outpatient review after 4 months. He has been compliant with medications and the community heart failure nurses have uptitrated to maximal tolerated doses.

His medications are Ramipril 10mg OD and Bisoprolol 5mg OD with Eplerenone 25mg OD.

He is clinically euvolaemic but remains breathless on exertion. You record he is in NYHA class II.

In addition he has noticed some palpitations. These happen infrequently and are short-lived. He describes them as his heart racing for a few seconds. He hasn’t felt dizzy or had any blackouts.

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Consider the questions below about the ongoing treatment in this case.