Nokea
A 58-year-old man with a known history of heart failure from cardiomyopathy, with an ejection fraction of 30 percent returns for a 3-week follow-up visit after being started on frusemide 40 mg od for increasing symptoms of dyspnea. Since starting frusemide, his symptoms have returned to baseline and he has lost 3 kg. He is maintained on guideline-directed medical therapy for heart failure including sacubitril/valsartan 97 mg/103 mg BD, carvedilol 12.5 mg BD, Simvastatin 40 mg ON, and aspirin 81 mg OD. His physical examination reveals: blood pressure of 128/80 mmHg, regular heart rate of 78 bpm, respiratory rate of 18 breaths/min, and room air oxygen saturation of 96 percent with no saturation decrease with hallway ambulation. He has no peripheral edema. A clinic electrocardiogram reveals a left bundle branch block with a QRS duration of >150 msec. What would be the most appropriate next step in management?
Correct Answer: A
Rationale: HFrEF at 30% EF with LBBB >150 msec stabilized on meds hints at dyssynchrony, ripe for cardiac resynchronization therapy, so an electrophysiologist's next. Ditching sacubitril/valsartan or swapping diuretics lacks cause; upping frusemide or re-echoing waits. Clinicians tap this referral, boosting chronic pump sync, a guideline nod.