Phys Written Answers · cardiovascular
Heart Failure — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for heart failure management, including problem-list synthesis, investigation interpretation, and integrated management planning.
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Target exams
SAQ 1 — Integrated Management (20 marks, 30 minutes)
Prompt: Outline your integrated management plan for this patient, including pharmacological changes, device therapy assessment, and comorbidity optimisation. Justify each decision with reference to evidence. [1]
Model Answer
Problem list (4 marks):
- HFrEF (LVEF 32%), NYHA III — newly diagnosed, not on GDMT
- Iron deficiency likely (screen required) — common in HF, worsens symptoms
- Paroxysmal AF on appropriate anticoagulation (apixaban)
- CKD stage 3B (eGFR 38) — cardiorenal overlap
- Type 2 diabetes (HbA1c 64) — needs SGLT2i
- Polypharmacy — needs reconciliation [1]
Pharmacological management — initiate four GDMT pillars (8 marks): [1]
| Pillar | Drug and dose | Rationale |
|---|---|---|
| ARNI | Sacubitril/valsartan 24/26mg BID (low dose due to BP/CKD), titrate toward 97/103mg BID. Must stop amlodipine (no evidence in HFrEF and adds to polypharmacy). 36-hour washout if switching from ACEi (she is not on one currently, so no washout needed). | PARADIGM-HF: 20% RRR vs enalapril. Preferred over ACEi/ARB. |
| Beta-blocker | Bisoprolol 1.25mg OD, titrate to 10mg OD | MERIT-HF: 34% mortality reduction. |
| MRA | Spironolactone 12.5mg OD (cautious given CKD), titrate to 25–50mg. Monitor K+ at 1 week, 1 month. | RALES: 30% mortality reduction in severe HF. |
| SGLT2i | Dapagliflozin 10mg OD (safe at eGFR 38; dual benefit for HF and diabetes) | DAPA-HF: 26% RRR worsening HF/CV death, independent of diabetes. Also lowers HbA1c and is renoprotective. |
Continue frusemide for symptom/congestion control. Stop amlodipine (no HF mortality evidence; unnecessary vasodilator in this context). [1]
Device therapy assessment (3 marks):
- Assess for ICD primary prevention: LVEF ≤35%, NYHA II–III, ≥3 months on optimal GDMT, expected survival >1 year. She qualifies once GDMT is optimised for ≥3 months.
- Assess for CRT: check QRS duration and morphology on ECG. If LBBB with QRS ≥150ms → CRT-D. If non-LBBB or narrow QRS → ICD only.
- Do not rush to device implantation — re-assess LVEF after 3–6 months of optimal GDMT; LVEF may recover above 35%, removing ICD indication. [1]
Comorbidity optimisation (3 marks):
- Iron studies: check ferritin and TSAT. If ferritin <100 or TSAT <20%, give IV ferric carboxymaltose (FAIR-HF: improves symptoms and exercise capacity).
- Diabetes: SGLT2i (dapagliflozin) addresses both HF and diabetes. Continue metformin; consider GLP-1 receptor agonist if weight management needed. Stop gliclazide if SGLT2i controls glucose (hypoglycaemia risk).
- Renal function: monitor closely with GDMT initiation. Acceptable creatinine rise up to 30%. SGLT2i is renoprotective long-term. [1]
Communication and follow-up (2 marks):
- Heart failure nurse referral for medication titration, education, and symptom monitoring.
- Medication reconciliation: patient is on 8+ medications; simplify regimen.
- Advance care planning discussion (appropriate at first clinic visit in advanced HF).
- Cardiac rehabilitation referral for exercise-based recovery. [1]
References
- [1]McMurray JJV, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure N Engl J Med, 2014.PMID 25176015
- [2]McMurray JJV, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction N Engl J Med, 2019.PMID 31535829