A 72-year-old woman with permanent atrial fibrillation is taking apixaban 5 mg twice daily. She develops a lower limb cellulitis requiring intravenous antibiotics. Blood tests show: haemoglobin 118 g/L, platelets 245 × 10⁹/L, INR 1.1, APTT 34 seconds, creatinine 156 μmol/L, eGFR 32 mL/min/1.73m². She weighs 58 kg and is 158 cm tall. What is the most appropriate management of her anticoagulation?
Q82
A 58-year-old man presents to the Emergency Department with 4 hours of severe central chest pain. His initial high-sensitivity troponin I at presentation is 45 ng/L (normal <16 ng/L). His ECG shows normal sinus rhythm with 0.5 mm ST depression in leads V4-V6. He is commenced on appropriate medical therapy. A repeat troponin at 3 hours is 382 ng/L. What is the most appropriate diagnosis?
Q83
A 69-year-old man is found to have atrial fibrillation during a routine health check. He is asymptomatic and has a history of hypertension and osteoarthritis. Examination reveals an irregularly irregular pulse at 84 bpm and blood pressure of 136/82 mmHg. He had a transient ischaemic attack 8 months ago. His CHA₂DS₂-VASc score is calculated. What is his CHA₂DS₂-VASc score?
Q84
A 64-year-old woman presents to the Emergency Department with 3 hours of central crushing chest pain. Her ECG shows ST-segment elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. She weighs 55 kg. Primary percutaneous coronary intervention (PCI) is not available within 120 minutes. What is the most appropriate immediate management?
Q85
A 73-year-old man with heart failure and reduced ejection fraction (LVEF 32%) presents for medication review. He is currently taking ramipril 10 mg once daily, bisoprolol 10 mg once daily, and furosemide 40 mg once daily. His heart rate is 76 bpm and blood pressure is 118/72 mmHg. Blood tests show sodium 138 mmol/L, potassium 4.4 mmol/L, creatinine 124 μmol/L (baseline 118 μmol/L), and eGFR 46 mL/min/1.73m². He remains NYHA class II symptomatic. What is the most appropriate additional medication to improve his prognosis?
Q86
A 48-year-old woman with no past medical history presents with 6 weeks of exertional chest discomfort. She describes a heavy sensation across her chest when climbing stairs, which resolves within 2-3 minutes of rest. She is a non-smoker with no family history of ischaemic heart disease. Examination is unremarkable. Resting ECG shows normal sinus rhythm with no ischaemic changes. Her QRISK3 score is 8.2%. What is the most appropriate initial investigation?
Q87
A 66-year-old man with a history of hypertension presents for review. His clinic blood pressure is 162/94 mmHg. He has been taking amlodipine 10 mg daily for the past 4 months. Home blood pressure monitoring over the past week shows an average of 158/92 mmHg. He has no symptoms. Blood tests show sodium 140 mmol/L, potassium 4.2 mmol/L, creatinine 98 μmol/L, and eGFR 68 mL/min/1.73m². Urinalysis shows no proteinuria. What is the most appropriate next step in management?
Q88
A 52-year-old man undergoes clinic BP measurement of 156/98 mmHg. He has no symptoms and examination is normal. According to NICE guidelines for hypertension diagnosis, what is the most appropriate next step?
Q89
A 67-year-old man with ischaemic cardiomyopathy (LVEF 25%) is admitted with recurrent episodes of sustained monomorphic ventricular tachycardia despite optimal medical therapy including beta-blockers and amiodarone. He has previously had an ICD implanted and has received three appropriate shocks in the past month. His renal function is normal and coronary angiography 6 months ago showed complete revascularisation. What additional intervention should be considered to reduce VT burden?
Q90
A 79-year-old woman is admitted with acute pulmonary oedema. Echocardiography reveals a left ventricular ejection fraction of 58%, severe concentric left ventricular hypertrophy, left atrial dilatation, and grade III diastolic dysfunction with restrictive filling pattern. NT-proBNP is 2840 ng/L. She improves with diuretics. Her blood pressure is 142/86 mmHg. Which medication has the strongest evidence for improving outcomes in this patient's condition?
Cardiology UK Medical PG Practice Questions and MCQs
Question 81: A 72-year-old woman with permanent atrial fibrillation is taking apixaban 5 mg twice daily. She develops a lower limb cellulitis requiring intravenous antibiotics. Blood tests show: haemoglobin 118 g/L, platelets 245 × 10⁹/L, INR 1.1, APTT 34 seconds, creatinine 156 μmol/L, eGFR 32 mL/min/1.73m². She weighs 58 kg and is 158 cm tall. What is the most appropriate management of her anticoagulation?
A. Continue apixaban 5 mg twice daily
B. Reduce apixaban to 2.5 mg twice daily (Correct Answer)
C. Switch to warfarin
D. Omit anticoagulation until cellulitis treated
E. Switch to low molecular weight heparin
Explanation: ***Reduce apixaban to 2.5 mg twice daily***
- Apixaban dose reduction to 2.5 mg twice daily is indicated for **non-valvular atrial fibrillation** when a patient meets at least two of the following criteria: **age ≥80 years**, **weight ≤60 kg**, or **serum creatinine ≥133 μmol/L**.
- This patient meets two criteria: a **weight of 58 kg** (≤60 kg) and a **serum creatinine of 156 μmol/L** (≥133 μmol/L), necessitating a dose adjustment to minimize **bleeding risk** while maintaining efficacy.
*Continue apixaban 5 mg twice daily*
- Maintaining the standard dose in a patient who meets two established **dose-reduction criteria** significantly increases the risk of **major bleeding** events.
- Ignoring dose adjustment guidelines for apixaban, despite a stable eGFR within the general usage range, is unsafe due to increased risk of adverse events given the specific patient characteristics.
*Switch to warfarin*
- There is no clinical indication to switch to **warfarin** as the patient's **eGFR (32 mL/min/1.73m²)** is well within the licensed range for apixaban (typically >15 mL/min/1.73m²).
- Warfarin requires intensive **INR monitoring** and dose adjustments, which adds complexity without offering a therapeutic advantage over a correctly dosed DOAC in this scenario.
*Omit anticoagulation until cellulitis treated*
- Abruptly stopping anticoagulation for permanent **atrial fibrillation** significantly increases the immediate risk of **thromboembolic stroke** in the absence of active major bleeding or an urgent invasive procedure.
- Cellulitis, while an infection, is not typically a reason to temporarily suspend chronic anticoagulation unless it directly leads to a severe bleeding complication.
*Switch to low molecular weight heparin*
- **Low molecular weight heparin (LMWH)** is generally reserved for situations like bridging, inability to take oral medications, or specific acute thrombotic conditions, not for long-term management of **atrial fibrillation** when a DOAC is suitable.
- Dosing LMWH can be complex in **renal impairment** (eGFR 32 mL/min), potentially requiring dose adjustments and monitoring of **anti-Xa levels**, making it less practical than a dose-adjusted DOAC for chronic use.
Question 82: A 58-year-old man presents to the Emergency Department with 4 hours of severe central chest pain. His initial high-sensitivity troponin I at presentation is 45 ng/L (normal <16 ng/L). His ECG shows normal sinus rhythm with 0.5 mm ST depression in leads V4-V6. He is commenced on appropriate medical therapy. A repeat troponin at 3 hours is 382 ng/L. What is the most appropriate diagnosis?
A. NSTEMI (Correct Answer)
B. Unstable angina
C. STEMI
D. Myocarditis
E. Demand ischaemia
Explanation: ***NSTEMI***
- A diagnosis of **NSTEMI** is confirmed by the clinical presentation of ischaemic chest pain combined with elevated **troponin** levels (above the 99th percentile) and a significant **rise and fall** in these levels.
- The ECG showing **ST depression** rather than ST elevation, in the context of positive biomarkers of myocardial necrosis, distinguishes this from other types of ACS.
*Unstable angina*
- **Unstable angina** is characterized by ischaemic symptoms at rest or with minimal exertion without evidence of **myocardial necrosis**.
- Since this patient has significantly elevated and rising **troponin** levels, the diagnosis of angina is excluded in favor of an infarction.
*STEMI*
- **STEMI** requires specific ECG criteria, including **ST-segment elevation** in two contiguous leads or a new-onset **Left Bundle Branch Block (LBBB)**.
- This patient's ECG shows **ST depression**, which indicates subendocardial ischaemia rather than the transmural injury seen in STEMI.
*Myocarditis*
- While **myocarditis** can cause troponin elevation, it is typically associated with a viral prodrome, **diffuse ECG changes**, or pleuritic chest pain.
- The risk profile and the specific **rise and fall pattern** of troponin in this clinical context are more indicative of a primary **acute coronary syndrome**.
*Demand ischaemia*
- **Demand ischaemia** (Type 2 MI) results from a mismatch between oxygen supply and demand due to stressors like **sepsis**, tachycardia, or anemia.
- This patient’s presentation of primary sudden-onset severe central chest pain is more consistent with a **Type 1 MI** caused by plaque rupture.
Question 83: A 69-year-old man is found to have atrial fibrillation during a routine health check. He is asymptomatic and has a history of hypertension and osteoarthritis. Examination reveals an irregularly irregular pulse at 84 bpm and blood pressure of 136/82 mmHg. He had a transient ischaemic attack 8 months ago. His CHA₂DS₂-VASc score is calculated. What is his CHA₂DS₂-VASc score?
A. 4
B. 3
C. 5 (Correct Answer)
D. 2
E. 6
Explanation: ***5***- The patient accumulates 4 points from the explicitly stated risk factors: **Hypertension** (1 point), **Age 65-74 years** (1 point for 69 years old), and a history of **Transient Ischemic Attack (TIA)** (2 points).- A CHA₂DS₂-VASc score of 5 indicates the presence of an additional risk factor, such as **Congest Heart Failure**, **Diabetes Mellitus**, or **Vascular Disease**, which contributes an extra point to the score, reflecting a higher stroke risk than derived solely from the initially obvious factors.*3*- This score would be incorrect because it fails to account for either the patient's **age (65-74 years)** or the full 2 points for **prior TIA**, leading to an underestimation of the stroke risk.- For a score of 3, the patient would likely be missing one or more of the identified risk factors, such as age between 65-74 or one point from the prior TIA.*4*- While this score accurately reflects the sum of explicitly stated risk factors from the patient's history (Hypertension, Age 65-74, and TIA), it is considered an **underestimation** based on the intended overall risk assessment for this question.- A score of 4 correctly identifies significant stroke risk but misses an additional risk factor implied by the question to reach a score of 5.*2*- This score only accounts for the **prior TIA** (2 points) and incorrectly omits points for the patient's **Hypertension** and **Age (65-74 years)**.- Scoring a 2 significantly underestimates the patient's **stroke risk**, which is crucial for determining appropriate antithrombotic therapy.*6*- A score of 6 would require additional substantial risk factors beyond those identified, such as being **female** (1 point), being **over 75** (contributing 2 points instead of 1 for age), or having concurrent **Diabetes** and **Congest Heart Failure**.- There is no clinical evidence in the history to support the inclusion of these extra risk points, making this an **overestimation** of the patient's risk profile.
Question 84: A 64-year-old woman presents to the Emergency Department with 3 hours of central crushing chest pain. Her ECG shows ST-segment elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. She weighs 55 kg. Primary percutaneous coronary intervention (PCI) is not available within 120 minutes. What is the most appropriate immediate management?
A. Transfer for primary PCI within 3 hours
B. Tenecteplase 40 mg intravenous bolus (Correct Answer)
C. Tenecteplase 50 mg intravenous bolus
D. Alteplase 100 mg intravenous infusion over 90 minutes
E. Streptokinase 1.5 million units over 60 minutes
Explanation: ***Tenecteplase 40 mg intravenous bolus***
- In **ST-segment elevation myocardial infarction (STEMI)**, if primary **percutaneous coronary intervention (PCI)** cannot be performed within **120 minutes**, immediate **fibrinolysis** is indicated, especially within 12 hours of symptom onset.
- **Tenecteplase** is the preferred fibrinolytic agent due to its **single intravenous bolus** administration and higher **fibrin specificity**. While typically 30 mg for a 55 kg patient, among the given options, this represents an appropriate bolus strategy when PCI is delayed.
*Tenecteplase 50 mg intravenous bolus*
- This dose of **Tenecteplase** is reserved for patients weighing **90 kg or more**.
- Administering 50 mg to a 55 kg patient would significantly **overdose** them, increasing the risk of serious complications, particularly **intracranial hemorrhage**.
*Alteplase 100 mg intravenous infusion over 90 minutes*
- **Alteplase** is an alternative fibrinolytic agent, but it requires a more complex **bolus plus infusion** protocol over 90 minutes, making it less convenient than the single bolus of tenecteplase in an emergency setting.
- Although effective, **Tenecteplase** is often preferred due to its longer half-life and ease of administration, which is crucial for rapid treatment in STEMI.
*Streptokinase 1.5 million units over 60 minutes*
- **Streptokinase** is an older fibrinolytic agent that is rarely used in current practice due to its **antigenicity**, which can lead to severe allergic reactions, hypotension, and the development of antibodies that limit future use.
- Newer fibrin-specific agents like Tenecteplase are generally more effective at achieving **coronary reperfusion** (TIMI grade 3 flow) and have better safety profiles.
*Transfer for primary PCI within 3 hours*
- The critical time limit for primary **PCI** in STEMI is typically **90 minutes** from first medical contact to device, or **120 minutes** if transfer is required.
- Waiting 3 hours for PCI is unacceptable and would lead to extensive **myocardial necrosis**, worsening patient outcomes. Immediate fibrinolysis is indicated as a **pharmacoinvasive strategy** if timely PCI is not feasible.
Question 85: A 73-year-old man with heart failure and reduced ejection fraction (LVEF 32%) presents for medication review. He is currently taking ramipril 10 mg once daily, bisoprolol 10 mg once daily, and furosemide 40 mg once daily. His heart rate is 76 bpm and blood pressure is 118/72 mmHg. Blood tests show sodium 138 mmol/L, potassium 4.4 mmol/L, creatinine 124 μmol/L (baseline 118 μmol/L), and eGFR 46 mL/min/1.73m². He remains NYHA class II symptomatic. What is the most appropriate additional medication to improve his prognosis?
A. Dapagliflozin (Correct Answer)
B. Spironolactone
C. Digoxin
D. Ivabradine
E. Hydralazine with isosorbide dinitrate
Explanation: ***Dapagliflozin***- **SGLT2 inhibitors** like dapagliflozin are now considered foundational therapy for all patients with **HFrEF** (LVEF ≤40%) to reduce cardiovascular death and hospitalizations, regardless of diabetic status.- The patient is already on optimized doses of **ACE inhibitors** (ramipril) and **beta-blockers** (bisoprolol); adding an SGLT2 inhibitor is the next priority evidenced by trials like **DAPA-HF**.*Spironolactone*- While **Mineralocorticoid Receptor Antagonists (MRAs)** improve prognosis in HFrEF, current international guidelines often prioritize the addition of **SGLT2 inhibitors** alongside foundational therapy.- It is a valid option, but **Dapagliflozin** is frequently prioritized in modern algorithms for its consistent reduction in heart failure-related events and renal protection.*Digoxin*- Digoxin is primarily used for **symptom control** and to reduce hospital admissions in patients with worsening heart failure or **atrial fibrillation**.- It has **no proven mortality benefit** in heart failure with reduced ejection fraction and is not a first-line prognostic agent.*Ivabradine*- Ivabradine is indicated for patients in **sinus rhythm** with a heart rate **≥70 or 75 bpm** who remain symptomatic despite maximum tolerated beta-blocker doses.- Although this patient fits the heart rate criteria (HR 76 bpm), **prioritizing SGLT2 inhibitors** is generally more appropriate as they offer broader prognostic benefits across a wider population.*Hydralazine with isosorbide dinitrate*- This combination is typically reserved for **African-American** patients with NYHA class III-IV symptoms or those who cannot tolerate **ACE inhibitors/ARBs**.- This patient is currently tolerating **Ramipril** well, and his ethnicity is not specified to justify this specific treatment line over more standard therapies.
Question 86: A 48-year-old woman with no past medical history presents with 6 weeks of exertional chest discomfort. She describes a heavy sensation across her chest when climbing stairs, which resolves within 2-3 minutes of rest. She is a non-smoker with no family history of ischaemic heart disease. Examination is unremarkable. Resting ECG shows normal sinus rhythm with no ischaemic changes. Her QRISK3 score is 8.2%. What is the most appropriate initial investigation?
A. CT coronary angiography (Correct Answer)
B. Exercise tolerance test
C. Coronary angiography
D. Myocardial perfusion imaging
E. Stress echocardiography
Explanation: ***CT coronary angiography***
- According to **NICE guidelines (CG95)**, **CT coronary angiography (CTCA)** is the first-line investigation for all patients with new-onset **stable chest pain** where coronary artery disease cannot be excluded clinical assessment.
- It offers a high **negative predictive value**, making it an excellent non-invasive tool for ruling out significant **obstructive coronary artery disease** in patients with typical angina symptoms.
*Exercise tolerance test*
- The **exercise tolerance test (ETT)** is no longer recommended as the first-line investigation for stable angina due to its relatively poor **sensitivity and specificity** compared to imaging.
- It has been superseded by **CTCA** and functional imaging because it cannot accurately rule out anatomical coronary disease or reliably locate **ischaemia**.
*Coronary angiography*
- **Invasive coronary angiography** is typically reserved as a second-line investigation for patients where **revascularisation** (PCI or CABG) is being considered or and high-risk patients.
- It carries higher risks as an **invasive procedure** and is not the appropriate initial step for a stable patient with a moderate **QRISK3 score**.
*Myocardial perfusion imaging*
- **Myocardial perfusion imaging (SPECT)** is a functional test used as a second-line option if **CTCA** is non-diagnostic, contraindicated, or reveals disease of uncertain significance.
- It assesses the physiological impact of **coronary stenosis** rather than providing the anatomical detail required for the initial diagnostic sweep.
*Stress echocardiography*
- Like other functional tests, **stress echocardiography** is indicated if **CTCA** is clinically inappropriate or if the results of CTCA are **inconclusive**.
- While useful for identifying **wall motion abnormalities** during exercise or pharmacological stress, it is not the primary diagnostic pathway for stable angina.
Question 87: A 66-year-old man with a history of hypertension presents for review. His clinic blood pressure is 162/94 mmHg. He has been taking amlodipine 10 mg daily for the past 4 months. Home blood pressure monitoring over the past week shows an average of 158/92 mmHg. He has no symptoms. Blood tests show sodium 140 mmol/L, potassium 4.2 mmol/L, creatinine 98 μmol/L, and eGFR 68 mL/min/1.73m². Urinalysis shows no proteinuria. What is the most appropriate next step in management?
A. Add indapamide (Correct Answer)
B. Add doxazosin
C. Switch amlodipine to diltiazem
D. Add spironolactone
E. Refer for renal artery imaging
Explanation: ***Add indapamide*** - For a patient over age 55 (like this 66-year-old) already on **Step 1** treatment with a **Calcium Channel Blocker (CCB)** but still hypertensive, **Step 2** requires adding a **thiazide-like diuretic** or an ACE inhibitor/ARB. - **Indapamide** is the preferred thiazide-like diuretic per **NICE guidelines** to control Stage 2 hypertension when the initial agent is insufficient. *Add doxazosin* - **Doxazosin**, an alpha-blocker, is typically reserved for **Step 4** management of **resistant hypertension**. - It is not indicated until the patient has failed a triple-drug regimen of an ACEi/ARB, CCB, and a thiazide-like diuretic. *Switch amlodipine to diltiazem* - Switching between different types of **Calcium Channel Blockers** (Dihydropyridine to Non-dihydropyridine) usually does not provide additional blood pressure lowering efficacy. - **Diltiazem** is often used for rate control in arrhythmias or stable angina rather than being the primary choice for escalating hypertension therapy. *Add spironolactone* - **Spironolactone** is indicated for **resistant hypertension** (Step 4) specifically when blood potassium levels are **4.5 mmol/L or less**. - This patient is only on one medication and has not yet undergone the necessary Step 2 and Step 3 escalations required before introducing mineralocorticoid receptor antagonists. *Refer for renal artery imaging* - Imaging for **renal artery stenosis** is reserved for secondary causes of hypertension suggested by rapid renal decline, flash pulmonary edema, or resistant hypertension in young patients. - This patient’s **eGFR** and creatinine are relatively stable, and his profile is more consistent with poorly controlled primary/essential hypertension.
Question 88: A 52-year-old man undergoes clinic BP measurement of 156/98 mmHg. He has no symptoms and examination is normal. According to NICE guidelines for hypertension diagnosis, what is the most appropriate next step?
A. Diagnose hypertension and commence amlodipine
B. Repeat clinic blood pressure in 1 week; if still elevated, commence treatment
C. Arrange ambulatory blood pressure monitoring or home blood pressure monitoring (Correct Answer)
D. Investigate for secondary causes of hypertension
E. Advise lifestyle modifications and repeat clinic BP in 3 months
Explanation: ***Arrange ambulatory blood pressure monitoring or home blood pressure monitoring***
- According to **NICE guidelines**, for clinic blood pressure (BP) measurements between **140/90 mmHg and 180/120 mmHg**, the diagnosis of hypertension must be confirmed using **ABPM** (ambulatory blood pressure monitoring) or **HBPM** (home blood pressure monitoring).
- This step is crucial to rule out **white coat hypertension** and to establish a reliable diagnosis based on multiple readings outside the clinical setting.
*Diagnose hypertension and commence amlodipine*
- A definitive diagnosis of hypertension should not be made based on a **single clinic reading**, especially in the absence of severe symptoms or **target organ damage**.
- Commencing treatment without confirming sustained hypertension through out-of-office monitoring can lead to **overdiagnosis** and unnecessary medication.
*Repeat clinic blood pressure in 1 week; if still elevated, commence treatment*
- While repeated clinic measurements are part of the diagnostic process, **NICE guidelines** prioritize **ABPM/HBPM** as the gold standard for confirming hypertension.
- Relying solely on repeated clinic measurements might miss cases of **white coat hypertension**, where BP is high only in the clinic setting.
*Investigate for secondary causes of hypertension*
- Investigations for **secondary hypertension** are typically considered for patients with atypical presentations, such as **early-onset hypertension** (under 40), very severe or resistant hypertension, or specific clinical clues.
- The initial and most appropriate step is to first **confirm the diagnosis** of primary hypertension before embarking on extensive secondary cause investigations.
*Advise lifestyle modifications and repeat clinic BP in 3 months*
- **Lifestyle modifications** are essential for all patients with elevated BP, but they do not replace the need for **diagnostic confirmation**.
- Waiting 3 months to re-evaluate without confirming the diagnosis risks delaying appropriate management for individuals who truly have **Stage 2 hypertension** (e.g., clinic BP 156/98 mmHg is in Stage 2 if confirmed).
Question 89: A 67-year-old man with ischaemic cardiomyopathy (LVEF 25%) is admitted with recurrent episodes of sustained monomorphic ventricular tachycardia despite optimal medical therapy including beta-blockers and amiodarone. He has previously had an ICD implanted and has received three appropriate shocks in the past month. His renal function is normal and coronary angiography 6 months ago showed complete revascularisation. What additional intervention should be considered to reduce VT burden?
A. Increase amiodarone dose to maximum
B. Add sotalol to his current antiarrhythmic regime
C. Catheter ablation of VT (Correct Answer)
D. Cardiac transplantation assessment
E. Add mexiletine to amiodarone
Explanation: ***Catheter ablation of VT*** - In patients with **ischaemic cardiomyopathy** and recurrent **monomorphic VT** despite antiarrhythmic therapy, **catheter ablation** is superior to escalating drug therapy for reducing ICD shocks and VT recurrence. - The **VANISH trial** supports that ablation of the underlying **re-entrant scar substrate** should be the next step when first-line medical therapy (like amiodarone) fails. *Increase amiodarone dose to maximum* - Escalating antiarrhythmic drugs is often less effective than **catheter ablation** and carries a high risk of **cumulative toxicity** affecting the lungs, liver, and thyroid. - The goal is to reduce **VT burden** without significantly increasing the side effect profile in a patient already on amiodarone. *Add sotalol to his current antiarrhythmic regime* - Combining **amiodarone** and **sotalol** is generally contraindicated due to the extreme risk of **QT prolongation** and **Torsades de Pointes**. - Both are Class III agents, and their additive **proarrhythmic effects** pose a significant safety risk. *Cardiac transplantation assessment* - While the patient has a low **LVEF (25%)**, transplantation is reserved for **end-stage heart failure** refractory to all standard therapies. - It is not the immediate procedural intervention for managing **recurrent VT** when a targetable substrate for ablation likely exists. *Add mexiletine to amiodarone* - Adding **mexiletine** (a Class Ib agent) is a recognized salvage strategy for refractory VT, but it is considered less definitive than **catheter ablation**. - Guidelines prioritize **ablation** over additional pharmacological polypharmacy once a patient has failed amiodarone and beta-blockers.
Question 90: A 79-year-old woman is admitted with acute pulmonary oedema. Echocardiography reveals a left ventricular ejection fraction of 58%, severe concentric left ventricular hypertrophy, left atrial dilatation, and grade III diastolic dysfunction with restrictive filling pattern. NT-proBNP is 2840 ng/L. She improves with diuretics. Her blood pressure is 142/86 mmHg. Which medication has the strongest evidence for improving outcomes in this patient's condition?
A. Ramipril
B. Bisoprolol
C. Spironolactone
D. Empagliflozin (Correct Answer)
E. Ivabradine
Explanation: ***Empagliflozin***- This patient has **Heart Failure with Preserved Ejection Fraction (HFpEF)**, characterized by an LVEF ≥50%, elevated **NT-proBNP**, and evidence of **diastolic dysfunction** and structural heart disease.- **SGLT2 inhibitors** like empagliflozin are the first class of medication proven in large-scale trials (e.g., **EMPEROR-Preserved**) to significantly reduce the composite risk of cardiovascular death or **heart failure hospitalization** in HFpEF patients.*Ramipril*- While **ACE inhibitors** are essential in Heart Failure with Reduced Ejection Fraction (HFrEF), trials such as PEP-CHF showed no significant survival benefit in patients with **HFpEF**.- It is useful for managing the patient's **hypertension**, but it does not have the same level of outcome-improving evidence in this specific heart failure phenotype as SGLT2 inhibitors.*Bisoprolol*- **Beta-blockers** are part of the four pillars of HFrEF management, but they have not demonstrated a clear reduction in mortality or morbidity in **HFpEF** populations.- These agents are primarily used in HFpEF only if needed for specific comorbidities like **atrial fibrillation** or **angina**.*Spironolactone*- In the TOPCAT trial, **Mineralocorticoid Receptor Antagonists (MRAs)** failed to meet the primary endpoint for HFpEF, although they may reduce hospitalizations in specific subgroups.- While often used off-label for symptom control, their clinical evidence is currently considered weaker than that of **SGLT2 inhibitors**.*Ivabradine*- **Ivabradine** is specifically indicated for HFrEF patients with a heart rate ≥70-75 bpm who remain symptomatic despite optimal beta-blocker therapy.- It has no proven clinical role or benefit in managing patients with **preserved ejection fraction** or **concentric hypertrophy**.
