Interventions associated with improved mortality in patients with heart failure. ..

A 70-year-old man, known to have ischemic heart disease and who has had a coronary artery bypass
graft in the past, presents with progressive breathlessness. He is haemodynamically stable but has
clinical signs of congestion and a Chest X Ray confirms pulmonary edema.
An ECG shows sinus rhythm with anterior Q waves, QRS complex of 180 ms duration (normal <120 ms) with a left bundle-branch block pattern.
Transthoracic echocardiography shows systolic left ventricular dysfunction with an ejection fraction of 25% (normal 50–60%).

Question
Which two of the following interventions would not be associated with an improved mortality in this patient?

A Loop diuretic
B Lisinopril
C Statin
D Implantable cardioverter
defibrillator
E Eplerenone
F Biventricular pacing
G Carvedilol
H Spironolactone
I Bisoprolol
J Diltiazem

Answer:

A Loop diuretic
J Diltiazem

Discussion: Loop diuretics may improve symptoms, but there is no evidence that they improve mortality.
Dihydropyridine calcium antagonists are contraindicated in heart failure.
Spironolactone and eplerenone are aldosterone antagonists and have been shown to improve mortality in patients with significant systolic left ventricular dysfunction who present with decompensated heart failure and in those with heart failure post myocardial infarction, respectively. Angiotensin-converting enzyme inhibitors and beta-blockers improve mortality in systolic heart failure.
Defibrillators reduce mortality from sudden death in post-myocardial infarction patients with low ejection fraction (<30%).
Biventricular pacemakers also improve prognosis in patients with ejection fraction <30% and left bundle-branch block.
Statins in the presence of proven coronary artery disease have been shown to improve outcome.