MRCP2-0096
A 65-year-old caucasian male presented to heart failure clinic with shortness of breath on exertion. He has a history of heart failure, initially diagnosed four years previously.
His current medications included ramipril, aspirin, bisoprolol, simvastatin and spironolactone. He is concerned that despite all of these medications his breathlessness is worsening. In addition to this he is now using four pillows to sleep at night.
On examination he is comfortable at rest with fine crackles at both lung bases and pitting oedema reaching up to both knees. His observations reveal a respiratory rate of 16 breaths per minute, oxygen saturation 96% in room air, blood pressure 110/85 mmHg, heart rate 70 beats per minute, temperature 37.2ºC.
His ECG revealed a normal sinus rhythm with narrow QRS complexes. A recent echocardiogram completed two weeks previously demonstrated an ejection fraction of 30%. His current medications were reviewed and he was found to be on the maximum dose for each of these.
His baseline U&E results are as follows:
Na+ 136 mmol/L (135 – 145)
K+ 4.5 mmol/L (3.5 – 5.0)
Bicarbonate 26 mmol/L (22 – 29)
Urea 6.7 mmol/L (2.0 – 7.0)
Creatinine 110 µmol/L (55 – 120)
What is the best course of treatment for this patient?