Heart failure — KFP-style written assessment

KFP 1 (10 marks)

A 64-year-old man presents with exertional breathlessness and orthopnoea. Examination: raised JVP, bilateral crackles, ankle oedema. NT-proBNP is elevated; echo shows LVEF 32%. BP 118/72 mmHg; potassium 4.2 mmol/L; eGFR 58 mL/min/1.73 m². ^[1]

1. Confirm the EF band and name all four drug classes he should leave on. (3) ^[1]
2. For each pillar, give one trial with its headline result. (4) ^[1][2]
3. State your monitoring plan for the next month. (3) ^[3]

Model answers

1. LVEF 32% = HFrEF (EF ≤40%). Four pillars: ARNI or ACEI, an evidence-based beta-blocker (bisoprolol, carvedilol, or metoprolol succinate), an MRA, and an SGLT2 inhibitor. ^[1][2]
2. ARNI: PARADIGM-HF — CV death/HF hospitalisation 21.8% vs 26.5% with enalapril (HR 0.80). Beta-blocker: MERIT-HF — mortality RR 0.66 with metoprolol succinate. SGLT2i: DAPA-HF — dapagliflozin HR 0.74 (16.3% vs 21.2%); EMPEROR-Reduced empagliflozin HR 0.75. MRA: mortality reduction established in HFrEF trials with potassium monitoring obligations. ^[1][2]
3. Urea, electrolytes, creatinine and potassium within 1–2 weeks of any initiation or up-titration; blood pressure and symptom review at each step; expect a small creatinine dip after starting the SGLT2 inhibitor and do not stop it for small declines. ^[3]