Heart Failure Drugs

A 65-year-old woman with NYHA Class II heart failure (EF 35%) is on ramipril 5 mg daily, bisoprolol 2.5 mg daily, and spironolactone 25 mg daily. She reports persistent dyspnoea on exertion and ankle oedema. Her BP is 105/68 mmHg, HR 72/min, K^+^ 4.2 mEq/L, and eGFR 52 mL/min/1.73m². What is the most appropriate next step in management?

A 62-year-old woman with acute decompensated heart failure (NYHA Class IV, pulmonary edema) on chronic furosemide is admitted to the ICU. She is hypotensive (SBP 92 mmHg) and oligouric. Before escalating to inotropic support, which investigation is most appropriate to differentiate the underlying hemodynamic state?

A 48-year-old woman with acute decompensated heart failure (ADHF) and pulmonary edema is admitted to the ICU. She is hypotensive (SBP 90 mmHg) and has signs of peripheral hypoperfusion. Intravenous furosemide and dobutamine have been initiated. Which investigation is most appropriate to assess the adequacy of tissue perfusion and guide further inotropic or vasopressor therapy?

A 72-year-old woman with a 15-year history of heart failure with reduced ejection fraction (EF 28%) is on lisinopril, metoprolol succinate, and spironolactone. Her recent echocardiogram shows no improvement in ejection fraction despite 6 months of optimal medical therapy. She remains symptomatic with NYHA Class III dyspnea. Her current medications are well-tolerated; serum creatinine is 1.2 mg/dL and potassium is 4.8 mEq/L. Her blood pressure is 110/70 mmHg and heart rate is 58/min. What is the most appropriate next addition to her regimen?

A 58-year-old man with a 3-year history of dilated cardiomyopathy (LVEF 28%) and symptomatic heart failure (NYHA Class III) is initiated on standard heart failure therapy. He is already on a beta-blocker and an ACE inhibitor. Which drug should be added next as the evidence-based third pillar of neurohormonal blockade?