1. Jennifer Bell British Heart Foundation Heart Failure Nurse Specialist

2. 80 year old male from Langholm Several HF admissions to Cumberland Infirmary Referred by GP Frusemide increased by 40mg

3. History Severe LVD Hypertension Allergic to ? Penicillin Mural thrombus in LV Bilateral subdural haematoma 2005 Parkinsons Prostatism Medication Zopiclone7.5mg prn Warfarin SodiumAs per INR Ramipril10mg od Furosemide40mg 2pm Furosemide80mg mane

4. Symptoms NYHA Class IV Paroxysmal Nocturnal Dyspnoea Severe Orthopnoea/Cheyne Stokes Respirations Signs BP (lying) 101/75 BP (standing) 106/71 Pulse 77 bpm Raised JVP Weight: 77.6 kg (BMI 23.2) Widespread creps Waist oedema U & E’s, FBC satisfactory ECG – NRS freq VE’s range 53-109 min

5. Plan Fluid restriction 1500mls Salt reduction <5g day Increase frusemide by 40mg Avoid sleeping tablet and consider Oramorph ? Acute hospital admission ? Palliative referral Add Spirolactone Beta blocker contraindicated meantime District nurses – suitable bed, pressure relieving mattress Social work dept – benefits, carer input, OT assessment ? Community hospital admission GP visit requested and further discussion re management Consider Metolazone Future D&G cardiology referral/follow-up

6. Actual outcome Admitted to Community Hospital Commenced Oramorph & Spironolactone Strict fluid restriction Discharged home 12 days later with community support 3 months later: NYHA Class III Progress stable BP (lying) 123/79 BP (standing) 117/78 Pulse 58 bpm Weight: 68 kg (BMI 20.3) Few creps No oedema Warfarin Sodium Ramipril10mg Spironolactone 25mg Bisoprolol Fumarate1.25mg Furosemide40mg 2pm Furosemide80mg mane Oramorph 2.5mg prn Picolax Macrogols Lactulose Senna

7. COMMENTS / QUESTIONS / SUGGESTIONS FOR FUTURE ? Palliative care referral/joint management ? Dietetic referral ? Cardiology follow up ? Candesartan ? Resynchronisation therapy if criteria met ? Up titrate beta-blocker ? try Nebivolol ? Change nothing meantime