QuestionSBA
QuestionChoice
Digoxin may help to control symptoms, however it does not provide a prognostic (i.e. mortality) benefit.
10035398
b
Add digoxin
QuestionChoice
This may be considered but is mostly used in African-Caribbean patients. From the options provided, cardiac resynchronisation therapy is the best intervention to choose that would provide a mortality benefit.
10035400
d
Add hydralazine and nitrate
QuestionChoice
This patient is clearly experiencing significant symptoms of dyspnoea due to heart failure with reduced ejection fraction. It would be inappropriate to leave her management unchanged unless the patient wished for this to be the case.
10035399
c
No changes to current management
QuestionChoice
This is not appropriate; sacubitril-valsartan (Entresto) is recommended INSTEAD of an ACE inhibitor/ARB in patients with an ejection fraction of less than 35%. The formulation includes an angiotensin receptor blocker (valsartan).
10035401
e
Substitute sacubitril-valsartan for an ACE inhibitor
QuestionChoice
This patient is clearly experiencing significant symptoms of dyspnoea due to heart failure with reduced ejection fraction. She is now at maximal medical therapy, including a beta blocker, mineralocorticoid receptor antagonist, and sacubitril-valsartan (which contains an angiotensin receptor blocker). The next step to improve her prognosis would addition of an SGLT-2 inhibitor such as empagliflozin or dapagliflozin, which are known to reduce mortality in patients with heart failure with reduced ejection fraction.
10035397
a
Add dapagliflozin
Concept
Chapter
2693
3798
Heart Failure
Topic
134
Cardiology
19483
Cardiac resynchronization therapy (CRT) is used in heart failure with reduced ejection fraction (EF) to improve ventricular coordination, enhance cardiac output, and reduce symptoms in patients with dyssynchrony.
A 67-year-old Caucasian woman with heart failure due to ischaemic heart disease is seen in an outpatient clinic. Her most recent echocardiogram shows an ejection fraction of 32% and an ECG shows sinus rhythm with broad QRS complexes.

Her current cardiac medications include:
* Bisoprolol 5mg PO OD
* Sacubitril-valsartan 24/26 mg PO OD
* Eplerenone 25mg PO OD
* Furosemide 20mg PO OD

On examination, she is visibly breathless on mobilising to the clinic room and has mild pitting oedema to both calves. Her observations are normal and her pulse is regular at 70 bpm.

What is the most appropriate next step to improve her prognosis?
a