Prompt

DCE long-case preparation: structured written reasoning for heart failure management, including problem-list synthesis, investigation interpretation, and integrated management planning.

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.

References2Show

[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

SAQ 1 — Integrated Management (20 marks, 30 minutes)

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.

References2Show

[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

Heart Failure — Written Clinical Reasoning

SAQ 1 — Integrated Management (20 marks, 30 minutes)

Model Answer

Heart Failure — Written Clinical Reasoning

SAQ 1 — Integrated Management (20 marks, 30 minutes)

Model Answer