Self-Assessment Questions

1. A 49-year-old man has heart failure with preserved ejection fraction (HFpEF), diabetes
mellitus, and hypertension. His blood pressure, which has improved during the past several
months, is currently 140/75 mm Hg with a heart rate of 70 beats/minute. His home drugs include
hydrochlorothiazide 25 mg/ day and metoprolol 50 mg twice daily. Which one of the following
would best prevent the progression of HFpEF in this patient?
A. Digoxin (px blm membutuhkan antiaritmia (tidak ada data ritme jantung) HR px masih
normal (60-100 denyut per menit). Digunakan utk perbaiki gejala pada HF apabila terapi lain spt ACE ato
BB sudah diberikan)
B. Candesartan
(sebagai alternative ACE inh(first choise)  px sudah mengkonsumsi diuretic lemah dan
BB. Sebelum mengkonsumsi yang, ACE atau diuretiknya diperbaiki terlebih dahulu)
C. Amiodarone.
D. Diltiazem.

2. Which one of the following best describes moderate diastolic impairment on

echocardiography?
A. Left atrial pressure.
B. Pulmonary artery pressure.
C. Left ventricular size.
Parameter di atas terutama dinilai berdasarkan ekokardiografi.Tanda-tanda disfungsi diastolik yang
ditemukan pada ekokardiografi antara lain Fungsi sistolik ventrikel kiri yang normal atau hanya sedikit
abnormal dengan fraksi ejeksi >40-50%.abnormalitas dari fase diastolik di mitral inflow (pada pasien
dengan irama sinus normal), profil aliran darah pada vena pulmonalis, serta rasio kecepatan awal
pengisian mitral dan ke-cepatan awal diastolik anulus mitral (E/E’) yang diukur dengan ekokardiografi
tissue doppler
D. E/A ratio.

Questions 3–9 pertain to the following case.

R.P. is an 80-year-old woman (height 5′5′′, weight 127 lb) being seen in the heart failure (HF)
clinic. She has a 2-week history of progressive dyspnea, 1+ peripheral edema, and mild
bronchiectasis. She also has a long-standing history of hypertension and recently received and
diagnoses of atrial fibrillation and kidney insufficiency. On physical examination, her blood
pressure is 145/80 mm Hg, and her heart rate is irregular at 65 beats/minute; her jugular venous
pressure (JVP) is 12 cm with a marked v wave. Auscultation detects bibasilar rales, a 2/6
systolic ejection murmur at the left sternal border, and an S4 gallop. There is also bilateral
2+ pitting edema in the lower extremities. Her echocardiography report indicates a left
ventricular ejection fraction (LVEF) of 55%, biatrial enlargement, left atrial mean pressure of
19 mm Hg (normal 4–12 mm Hg), pulmonary artery pressure of 55 mm Hg (normal 15–30 mm
Hg), right atrial pressure of 10 mm Hg (normal 2–6 mm Hg), and severe tricuspid regurgitation
and mild mitral regurgitation. Her N-terminal pro–B-type natriuretic peptide (NT-proBNP)
concentration is 240 pg/mL, and CrCL is 25 mL/minute. R.P.’s current drugs, all taken orally,
include amlodipine 10 mg/ day, warfarin 4 mg/day, metoprolol 25 mg twice daily, and irbesartan
150 mg/day.

3. Which one of the following best describes the primary cause of R.P.’s clinical presentation?
A. Atrial fibrillation.
B. Left-sided filling pressures.
Tekanan pengisian sisi kiri (pada HF terjadi gangguan relaksasi dan pengisian ventrikel.NT-
proBNPdisintesis dan dilepaskan dari ventrikel sebagai respons adanya tekanan/tarikan dinding
miokard. Pada pasien kadarnya rendah, pada gangguan HFpEF kadar harusnya tinggi)
C. Hypertension.
(LVEF px masih bagus yaitu 55%, HFpEF penurunan distensibilitas ventrikel kiri yang
disebabkan oleh proses lamanya hipertensi, pada px tekanan arteri semua sisi meningkat
sehingga kondisi klinik speerti sesak, edema karena hipertensi)
D. Mitral regurgitation.

4. Which one of the following best describes the number of risk factors for HFpEF present in
R.P.?
A. One.
B. Two.
C. Three. (long-standing history of hypertension; echocardiography report indicates a left
ventricular ejection fraction (LVEF) of 55%; Auscultation detects bibasilar rales, a 2/6
systolic ejection murmur at the left sternal border, and an S4 gallop)
D. Four.

5. Which one of the following best differentiates HFpEF from heart failure with reduced ejection
fraction (HFrEF) in R.P.?
A. S4 gallop. (pemeriksaan fisik jantung dengan mendengar ritme jantung. Bunyi jantung 4 (S4),
terdengar, karena vibrasi dari dinding ventrikel selama kontraksi atrium.Bunyi ini biasanya dihubungkan
dengan penegangan ventrikel, dan dan oleh karena itu bunyi ini terdengar pada pasien hipertropi
ventrikel, miokardi iskemia, atau pada orang tua.
B. JVP. (pengukuran tekanan vena scr tdk langsung. JVP menggambarkan volume pengisian dan tekanan
pada jantung bagian kanan. Tekanan pada vena jugularis sama dengan level yang berhubungan dengan
tekanan pada atrium kanan ( vena sentral ))
C. Progressive dyspnea.
D. LVEF.
yang membedakanHFrEF dengan HFpEF adalah pada output fraksi ejeksi dari jantung
(LVEF) dimana HFrEF adl Gagal jantung sistolik dengan ketidakmampuan kontraksi jantung
memompa sehingga curah jantung menurun (LVEF < 50%) dan HFpEF adalah Gagal jantung diastolik
dengan penurunan distensibilitas ventrikel kiri yang disebabkan oleh proses menua hipertensi,
kardiomeopati hipertropik serta restriktif (LVEF masih normal / sedikit menurun ≥ 50%).

6. Which one of the following is the best interpretation of R.P.’s NT-proBNP results?
A. B-type natriuretic protein (BNP) would provide more utility than NT-proBNP. (keduanya
bermanfaat)
B. Both BNP and NT-proBNP concentrations should be assessed.
(BNP) disintesis dan dilepaskan dari ventrikel sebagai respons adanya tekanan/tarikan dinding
miokard.BNP dimetabolisme menjadi bentuk aktif dan bentuk degradasinya dikenal sebagai peptida
natriuretik tipe pro-B ujung-N (N-terminal pro-b-type natriuretic peptide, NT-proBNP), yang keduanya
dapat diukur dalam plasma. NT-proBNP memiliki waktu paruh lebih panjang sekitar 2 jam
dibandingkan BNP yang hanya 18 menit. Kadar dalam plasma meningkat baik pada HFpEF maupun
HFrEF walaupun cenderung lebih tinggi pada HFrEF.Kadar BNP dan NT-proBNP sesuai status klinis
pasien HF yaitu cenderung meningkat jika HF memburuk dan sebaliknya menurun jika kondisi HF
membaik. Pengukuran kadar BNP atau NT-proBNP plasma mungkin membantu dalam diagnosis dan
membedakan HF dari kondisi lain yang berkaitan dengan dispneu dan penurunan kapasitas kerja
(exercise).
C. Galectin-3 would better identify diastolic dysfunction than NT-proBNP.
D. The utility of NT-proBNP may be confounded by the patient’s comorbidities. (keduannya
daopat dikacaukan dg kondisi pasien)

7. Which one of the following would be the most appropriate blood pressure goal for R.P.?
A. Less than 140/90 mm Hg.
 Berdasarkan JNC 7,8; ASH; ACC/AHA BP untuk pasien dengan gangguan CVD
adalah <140/90 mmHg. Pasien memiliki gangguan pada CVD seperti AF, hipertensi yang
tidak terkontrol dll)
B. Less than 135/85 mm Hg.
C. Less than 130/80 mm Hg.
D. Less than 120/75 mm Hg.

8. Which one of the following would be the best add-on antihypertensive therapy for R.P.?
A. Furosemide 40 mg/day.
pasien mengalami edema ekstremitas bawah kemudian, ClCr px juga dibawah normal.
Sehingga perlu diberikan diuretic.
B. Verapamil SR 180 mg/day.
C. Hydrochlorothiazide 25 mg/day.
D. Spironolactone 12.5 mg/day.

9. Which one of the following lifestyle modifications would be most appropriate for R.P.?
A. Restrict sodium intake to less than 2–3 g/day.
B. Reduce body mass index to less than 18.
C. Restrict fluid intake to less than 1.5 L/day.
D. Initiate a high-carbohydrate diet.
left ventricular ejection fraction (LVEF) of 55%, biatrial enlargement, left atrial mean pressure
of 19 mm Hg (normal 4–12 mm Hg)  HFpEF
Pasien obesitas, obesitas sebagai faktor resiko dari HF, maka non-pharmacologic terapi yang
perlu dilakukan adalah menurunkan indeks massa hingga kurang dari 18.

10. Which one of the following best describes the risk of death in patients with HFpEF compared
with HFrEF?
A. Diabetes mellitus and cerebrovascular accident increase risk of death in HFpEF versus
HFrEF.
B. Diabetes mellitus and cerebrovascular accident increase risk of death in HFrEF versus
HFpEF.
C. Diabetes mellitus, but not cerebrovascular accident, increases risk of death in HFpEF versus
HFrEF.
D. Cerebrovascular accident, but not diabetes mellitus, increases risk of death in HFpEF versus
HFrEF.
Ambulatory patients with less advanced HFpEF are also older, anemic, and hypertensive, and
they tend to have higher prevalence of diabetes mellitus, cerebrovascular accident, and chronic
obstructive pulmonary disease than ambulatory patients with reduced HF (Ather 2012).
E.W. is a 71-year-old man (height 5′7′′, weight 300 lb) with a 1-year history of hypertension.
After an aortic valve replacement for aortic stenosis, he was referred to your HF clinic with
increasing dizziness during the past few days. His medical history is significant for chronic
obstructive pulmonary disease (COPD). Results of his physical examination are blood pressure
89/55 mm Hg (baseline 125/87 mm Hg), heart rate 120 beats/minute, and Sao2 95% on room air.
E.W. has no JVP, rales, or edema, but distant heart sounds with 1/6 systolic ejection murmur are
noted. He has no other significant physical findings. Chest radiography is clear with no
infiltrates. His laboratory findings include SCr 3.0 mg/dL (previously 1.0) and BUN 63 mg/ dL.
E.W.’s current oral drugs include warfarin 5 mg/day, amlodipine 10 mg/day, furosemide 60
mg/day, and inhalers. His echocardiography report shows an EF of 55%. Serum lipids are TC
220 mg/dL, LDL cholesterol 135 mg/dL, HDL cholesterol 55 mg/dL, and TG 150 mg/dL.
11. Given E.W.’s presentation, which one of the following etiologies is most likely responsible
for his HFpEF?
A. Hypertension.
B. Aortic stenosis.
C. COPD.
D. Obesity.

12. Which one of the following is most appropriate for E.W. at this time?
A. Increase his dose of inhalers.
B. Assess his INR.
C. Reduce amlodipine to 5 mg orally daily.
D. Reduce furosemide dose to 20 mg/day.
Nilai Scr dan BUN pasien diatas normal, menandakan adanya kerusakan ginjal, pemberian
diuretic dosis tinggi semakin memperparah kondisi ginjal.
13. Although E.W. is no longer experiencing dizziness, he has new-onset atrial fibrillation with
rapid ventricular response. Which one of the following would be best to recommend for
cardioversion in this patient?
A. Dofetilide
B. Diltiazem.
C. Amiodarone.
D. Dronedarone.
Dronedarone has also been studied as a rate-controlling agent for atrial fibrillation. The ERATO
trial (Efficacy and safety of dRonedArone for The control of ventricular rate during atrial
fibrillation) enrolled 174 subjects (older than 21 years, predominantly elderly males >65 years)
with permanent atrial fibrillation of more than 6 months’ duration and had a 6-month follow-up
period. The patients were randomized to receive 800 mg of dronedarone daily or placebo.
14. E.W.’s blood pressure is currently 118/70 mm Hg. The cardiologist initiates a statin but
requests your advice about the potential benefits it could provide. Which one of the following is
the best reason to initiate a statin in E.W.?
A. Improve HDL cholesterol.
B. Improve LDL cholesterol.
C. Increase fibrosis.
D. Reduce afterload.
Statin membantu menurunkan kadar kolesterol LDL (low-density lipoprotein). Jika darah
mengandung terlalu banyak LDL, maka lemak ini dapat menumpuk dan berkerak di dinding
pembuluh darah sehingga menurunkan aliran darah dan menimbulkan penyumbatan.LDL
banyak dihubungkan dengan peningkatan risiko penyakit jantung koroner.
15. A 55-year-old woman with HFpEF comes to the outpatient medicine clinic. Her blood
pressure is 135/85 mm Hg, and her heart rate is 130 beats/minute. She has no other comorbidities
or abnormalities. Which one of the following would be best to initiate in this patient?
A. Enalapril.
B. Metoprolol.
C. Diltiazem.
D. Hydrochlorothiazide.
Terapi gagal jantung dengan fraksi ejeksi yang masih dipertahankan (HFpEF) terutama adalah
diuretics dan vasodilators untuk meredakan/mengurangi kongesti pulmonar.
16. You are asked by the multidisciplinary team to provide information about the role of
advanced glycation end-product crosslink breakers in HFpEf. Which one of the following
statements most accurately describes these novel agents?
A. They act on excessive crosslinks in the myocardium but not on vasculature.
B. They reduce left ventricular mass, diastolic function, and remodeling.
C. They reduce intracellular calcium, leading to improved diastolic relaxation.
D. They reduce pressure-induced ventricular hypertrophy and fibrosis.
In one open-label study with 23 HF patients (LVEF >50%), 16 weeks of treatment with the AGE breaker
alagebrium resulted in improvements in LV mass and LV diastolic filling, along with improvements in
quality of life.
AGE-related crosslinking contributing to diastolic dysfunction in HFpEF patients, prompted studies in this
group with the crosslink breaker Alagebrium. An initial small size study showed promise that Alagebrium
improves LV diastolic filling and quality of life in HFpEF patients.

17. A 82-year-old woman recently received a diagnosis of HFpEF and new-onset cough. She has
a history of obesity, diabetes mellitus, and hypertension. From her history, which one of the
following best describes this patient’s number of modifiable risk factors?
A. One.
B. Two.
C. Three.
D. Four.
Jawaban:
Gangguan pada pengisian ventrikel kiri yang disebabkan oleh ketidaksempurnaan relaksasi atau
disfungsi distolik LV juga mengakibatkan berkurangnya luaran jantung, dan biasanya LVEF
hanya sedikit berkurang atau tetap normal (lebih dari 40-50%). Gagal jantung ini disebut
gagal jantung dengan fraksi ejeksi terjaga (HFpEF). Biasanya disebabkan karena hipertensi.
Batuk dapat menginduksi tekanan darah naik, diberi herbal yang tidak kontraindikasi. Modifikasi
berat badan dengan makan dan aktivitas yang sesuai. Memanajemen diabetes melitus dan
hipertensi dengan pola hidup dan terapi yang diterima.

18. Which one of the following best describes the difference between the prognoses of HFrEF
and HFpEF?
A. The short-term mortality rate is lower with HFrEF than with HFpEF.
B. The long-term mortality rate is lower with HFrEF than with HFpEF.
C. The functional status of patients with HFrEF is similar to that of patients with HFpEF.
D. Functional status declines over time with both HFpEF and HFrEF.
Jawaban:
Gagal jantung juga dapat diklasifikasikan berdasarkan defek primer fungsi miokard yang
mengakibatkan berkurangnya luaran jantung. Gangguan pada kemampuan jantung
memompa darah atau disfungsi sistolik LV, yang biasanya mengakibatkan fraksi ejeksi
ventrikel kiri (LVEF) kurang dari 40% disebut gagal jantung dengan penurunan ejeksi
(HFrEF).Gangguan pada pengisian ventrikel kiri yang disebabkan oleh ketidaksempurnaan
relaksasi atau disfungsi distolik LV juga mengakibatkan berkurangnya luaran jantung, dan
biasanya LVEF hanya sedikit berkurang atau tetap normal (lebih dari 40-50%). Gagal
jantung ini disebut gagal jantung dengan fraksi ejeksi terjaga (HFpEF).
Patients with HFrEF can take steps to manage their low ejection fraction, notably by limiting salt
consumption, managing fluid intake and exercising regularly. Those whose HFrEF becomes
severe or unmanageable may benefit from an implantable cardioverter defibrillator, which
regulates heart rhythm. For patients with HFpEF, there is not yet an optimal treatment modality.
Recent studies have suggested some utility for aldosterone agonists and metalloproteinase
inhibitors. However, additional research is warranted to find future treatments for HFpEF.

19. Which one of the following best describes the current evidence supporting the potential role
of spironolactone in patients with HFpEF?
A. Reduces fibrosis and inflammation in experimental studies.
B. Improves diastolic function through antihypertensive effects.
C. Improves left ventricular long-axis strain rate after 6 months of therapy.
D. Reduces sudden cardiac death in symptomatic patients.
Jawaban:
Death from cardiovascular causes occurred in 160 patients in the spironolactone group (9.3%)
and 176 patients in the placebo group (10.2%), with a hazard ratio of 0.90 (95% CI, 0.73 to 1.12;
P=0.35 by the log-rank test) (Figure 2AFIGURE 2 Kaplan–Meier Plots of Two Components of
the Primary Outcome.). Aborted cardiac arrest occurred in 3 patients in the spironolactone group
(0.2%) and 5 patients in the placebo group (0.3%) (P=0.48 by the log-rank test). Hospitalization
for heart failure occurred in 206 patients in the spironolactone group (12.0%) and 245 patients in
the placebo group (14.2%), with a hazard ratio of 0.83 (95% CI, 0.69 to 0.99; P=0.04 by the log-
rank test) (Figure 2B). Approximately two thirds of first primary-outcome events were
hospitalizations for heart failure. In an analysis of total hospitalizations (including repeat
hospitalizations) for heart failure over the entire study period, the frequency was lower in the
spironolactone group than in the placebo group (394 vs. 475 hospitalizations; 6.8 vs. 8.3 per 100
person-years; P=0.03).

20. Seorang pasien laki-laki, XB, 54 tahun, dirawat inap 6 kali dalam 6 bulan terakhir untuk
gagal jantung akut dekompensasi (acute decompensated heart failure) karena ketidakpatuhan
obat dan diet. Terakhir dirawat inap satu bulan lalu.Riwayat penyakitnya kardiomiopati NYHA
kelas III (left ventricular ejection fraction (EF) 30%), DM, dan penyakit ginjal stadium 3.
Obat yang diresepkan:
• lisinopril 10 mg/hari per oral,
• carvedilol 25 mg 2x/hari per oral,
• furosemid 40 mg 2x/hari per oral dan
• insulin glargin 35 unit.
Dari beberapa hal berikut, yang didiskusikan dengan pasien ketika akan pulang, yang
paling mungkin meminimalkan frekuensi rawat inapnya adalah:
A. Membatasi cairan hingga kurang dari 1 L/hari dan sodium menjadi kurang dari 1
g/hari.
B. Menimbang berat badan sendiri setiap hari dan menghubungi tim kesehatannya jika
bobot badan meningkat.
C. Vaksinasi influenza 0,5 mL intramuskuler secepatnya.
D. Mengenali gejala yang berkurang dan mengurangi dosis ACEi.
Jawaban:
ACEi dapat menurunkan angka hospitalisasi ~ 30%
1. Prevent further cardiac injury.
a. Discontinue smoking.
b. Reduce weight if obese.
c. Control HTN.
d. Control diabetes mellitus.
e. Minimize alcohol to 2 or fewer drinks a day for men and 1 orfewer drinks a day
for women.
a. Eliminate alcohol if cardiomyopathy is alcohol induced.
b. Limit Na intake to 1500 mg/day for stages A and B consider less than 3 g/day for
stages C and D.
2. Restricting fluid intake to 1.5–2 L/day is reasonable instage D if serum sodium is low.

21. Seorang pasien wanita, AJ, 23 tahun mengalami kardiomiopati 6 minggu setelah melahirkan
anak pertamanya setahun yang lalu. Riwayat penyakit lainnya DM tipe 2 yang didiagnosis
sebelum kehamilan dan menurut catatan kurang merespon konseling diet.Pasien ini dirawat inap
4 hari lalu dengan gejala nafas pendek saat istirahat, ortopneu, dan edema saat dicubit.
Regimen obatnya saat ini:
• furosemid 40 mg 2x/hari per oral,
• enalapril 5 mg 2x/hari per oral, dan
• glyburide (glibenklamid) 10 mg 2x/hari per oral.
Pasien akan dipulangkan setelah pemberian diuretik agresif intravena untuk mengatasi kelebihan
cairannya. Setelah kembali ke bobot badan keringnya, pasien tidak lagi menunjukkan gejala.
Hasil laboratorium pada saat masuk rumah sakit HbA1c nya 11,2 mg/dL dan SCr 1,8 mg/dL.
Berikut ini merupakan pilihan terbaik untuk mengatasi DM pasien:
A. Melanjutkan glibenklamid 10 mg 2x/hari per oral.
B. Mulai pioglitazone 15 mg 1x/hari per oral.
C. Mulai pemberian metformin 500 mg 2x/hari per oral.
D. Mulai pemberian insulin glargin (Lantus) 10 unit/hari subkutan.
Jawaban:
Nilai HbA1C yang tinggi menunjukkan ketidakpatuhan pasien dalam meminum obat
antidiabetes. In conclusion, the findings of Simpson and colleagues3 add to the existing evidence
that suggests that sulfonylureas increase the risk of cardiovascular events; furthermore, their
study adds support to a causal link by demonstrating a dose-related effect on the risk of death.
Sulfonylurea drugs should therefore be relegated to third-line agents (after metformin and
thiazolidinedione drugs) for managing type 2 diabetes — a conclusion also made in recently
published guidelines.13 If sulfonylurea drugs must be included in a treatment regimen to
maintain euglycemia, traditional agents should be avoided; agents such as glimepiride, glicizide
and nateglinide, which have less effect on myocardial ATP-sensitive potassium channels,10
should be prescribed instead.

22. Seorang pasien laki-laki , KZ, berusia 45 tahun datang dengan kardiomiopati hipertensif yang
diklasifikasikan ke dalam NYHA kelas I/II. Obatnya saat ini enalapril 20 mg dan carvedilol 50
mg, keduanya per oral setiap 12 jam.Pasien mulai menggunakan carvedilol sejak 3 bulan lalu,
dan fraksi ejeksi ventrikel kirinya naik dari 42% menjadi sekitar 55%.Pemeriksaan fisik
menunjukkan tekanan darah 157/85 mmHg dan nadi 80 bpm. Hasil laboratorium: kalium 5,1
mEq/L dan SCr 0,9 mg/dL. Pilihan berikut akan mengoptimalkan terapi pasien:
A. Menghentikan carvedilol 50 mg 2x/hari per oral.
B. Menambah amlodipin 5 mg/hari per oral.
C. Menambah losartan 25 mg/hari per oral.
D. Menambah verapamil sustained release 120 mg/hari per oral.
Jawaban:
23. Seorang laki-laki, MN, usia 45 tahun, dengan kardiomiopati non-iskemik NYHA klas II yang
diakibatkan oleh hipertensi yang sudah lama tidak terkontrol, datang ke klinik dengan dispneu
pada kerja fisik sedang.
Saat ini regimen obat untuk gagal jantungnya terdiri dari
• furosemid 40 mg per oral dua kali sehari dan
• lisinopril 5 mg per oral sekali sehari.
Obat berikut akan memberikan manfaat terbesar dalam mengurangi mortalitas semua-
sebab:
A. Metoprolol suksinat 25 mg/hari per oral.
B. Spironolakton 12,5 mg/hari per oral.
C. Losartan 12.5 mg/hari per oral.
D. Digoxin 0,125 mg/hari per oral.
Jawaban:
24. Seorang laki-laki, LG, usia 53 tahun dengan kardiomiopati idiopati dilasi datang ke klinik
dengan keluhan dispneu pada kerja fisik yang minimal. Pemeriksaan fisik menunjukkan vena
leher normal, ritme jantung dan nadi normal, auskultasi paru bersih, dan hanya sedikit
edema.Pasien saat ini pada kondisi bobot kering basal.
Regimen obat gagal jantungnya:
• furosemid 80 mg 2 kali/hari peroral,
• enalapril 10 mg 2x/hari per oral, dan
• metoprololextended release 150 mg 1x/hari per oral.
Data klinis yang stabil pada kunjungan kliniknya saat ini:
• TD 110/67 mmHg
• Nadi 53/menit
• Potasium 5,2 mEq/L
• BUN 17 mg/dL
• Kreatinin serum (SCr) 2,1 mg/dL
Berikut ini adalah pendekatan terbaik untuk mengatasi gagal jantung pasien ini:
 A. Mulai pemberian amlodipin 5 mg/hari per oral, mengurangi furosemid menjadi 40 mg
2x/hari per oral.
B. Mulai pemberian hidralazin 37,5 mg dan isosorbid dinitrat 20 mg 3x/hari per oral.
C. Mulai pemberian spironolakton 25 mg/hari per oral.
D. Meningkatkan metoprolol extended release menjadi 200 mg/hari per oral.
Jawaban:
Spironolakton merupakan golongan diuretik hemat kalium, dosis 25 mg per hari untuk edema
pasien.