Question

A 64-year-old man with ischaemic cardiomyopathy (left ventricular ejection fraction 30%) remains symptomatic with exertional dyspnoea (New York Heart Association class II-III) despite optimised doses of an ACE inhibitor, beta blocker and mineralocorticoid receptor antagonist. He has type 2 diabetes and an estimated GFR of 55 mL/min/1.73 m². Blood pressure is 118/70 mmHg. According to contemporary heart failure management, what is the most appropriate next pharmacological step?

Accepted Answer

Start an SGLT2 inhibitor such as empagliflozin, provided there are no contraindications.

Answer

Add a thiazide diuretic for additional blood pressure lowering.

Answer

Increase the beta-blocker dose above the recommended maximum to achieve heart rate <50 beats/min.

Answer

Stop the ACE inhibitor and switch to a short-acting nitrate.

Answer

Commence long-term amiodarone for primary prevention of sudden cardiac death.

Practice question