Heart Failure

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Step 1: View clinicals

A 61 year old man presents with worsening exertional dyspnea for 3 months and orthopnea for 2 weeks. His medical history is significant for an anterior STEMI 4 years ago. No other co-morbidities are present. He is currently on aspirin, prasugrel, metoprolol, telmisartan and rosuvastatin.


Step 2: Order all relevant investigations

Chest X-Ray

There is gross cardiomegaly, with plethoric lung fields. Both costophrenic angles are obliterated.

ECG

The ECG shows atrial fibrillation with a left bundle branch block.

Echocardiography

The ejection fraction is 40%. The left ventricle and atrium are dilated, while marked abnormalities of the anterior wall are noted. Mild mitral regurgitation is present.

Coronary Angiography

Coronary angiography shows a right dominant circulation with a 90% stenosis of the Left Anterior Descending (LAD) artery.


Step 3: Select appropriate management

Spironolactone
Digoxin
Amlodipine
Pacemaker implantation


Score: ★★☆