MRCP2-0463

MRCP2-0463

A 72-year-old man presents to the Emergency Department at 5 am with acute shortness of breath, such that he feels he is going to die.

He has a history of four previous myocardial infarctions and NYHA class II heart failure. Medication includes Ramipril 10 mg, atorvastatin 20 mg, furosemide 40 mg, and aspirin 75 mg.

On examination his BP is 165/100, pulse is 88 and regular. Heart sounds are normal. There are crackles to the mid zones bilaterally on auscultation of the chest. His respiratory rate is 28, and O2 saturation is 90% on air. There is mild pitting oedema of both ankles.

Investigations:

Hb 120 g/l (135-180)

WCC 7.3×10(9)/l (3.8-10.8)

PLT 238×10(9)/l (150-450)

Na 134 mmol/l (135-145)

K 5.4 mmol/l (3.5-5.5)

Bicarbonate 19 mmol/l (18-28)

Cr 132 micromol/l (60-110)

ECG Sinus rhythm, right bundle branch block, anterior Q waves, anterior T wave inversion

CXR Bilateral upper lobe diversion, interstitial shadowing consistent with heart failure

What is the most appropriate intervention in this case?