On your ward round you review a patient who is 48 hours post anterior STEMI treated successfully with primary angioplasty. He has type 2 diabetes and hypertension. He is gradually improving, having initially suffered with heart failure. He still feels ‘chesty’ and auscultation reveals minimal basal crepitations. Echocardiography has revealed an ejection fraction of 40%. Blood pressure is 110/70 mmHg with heart rate 55 bpm at rest. Ramipril has been titrated to 2.5 mg bd with bisoprolol 2.5mg od. U&Es have remained normal.
How would you improve his medical treatment?
A. Add furosemide 40 mg odAldosterone antagonists are indicated if EF ≤ 40% (EPHESUS trial) or if there is heart failure or diabetes, provided that there is no renal failure or hyperkalaemia. The diuretic action should help with the mild residual congestion. Blood pressure will appear to limit further titration of the ACE inhibitor at this stage.