MEDizzy - A 57-year-old woman with known heart failure and EF 42% is

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Heart failure

A 57-year-old woman with known heart failure and EF 42% is reviewed in clinic. She is breathless on walking up one flight of stairs or half a mile on the flat. On examination, her BP is 130/90 mmHg and her heart rate is 75 bpm (SR, ECG QRS < 120 ms). Her chest is clear to auscultation. There are no signs of fluid overload. Her current medication is carvedilol 25 mg bd, furosemide 40 mg od, and digoxin 62.5 micrograms od. Her recent renal function tests are Na 141 mmol/L, K 5.1 mmol/L, urea13.5 mmol/L, and creatinine 236 μmol/L. She has not previously tolerated an ACE inhibitor or spironolactone because of deteriorating renal function and hyperkalaemia. What would you do next?

ExplanationAn ACE inhibitor should only be used in patients with adequate renal function (creatinine ≤221 mmol/L or ≤2.5 mg/dL or eGFR ≥30 mL/min/1.73 m2 ) and a normal serum potassium level. Candesartan and epleronone are also contraindicated in view of the renal function. Furosemide is not indicated because of fluid status. Ivabradine requires an EF <35%. H-ISDN is an alternative to ACE inhibitor/ARB when they are not tolerated, or can be considered in patients on maximal therapy and residual NYHA class II–IV symptoms and EF ≥35%.