Case discussion
Breathlessness in a Patient with Reduced Ejection Fraction
A step-by-step clinical case discussed at the October 2026 academic meeting. Read each step and think through your approach before revealing the next.
The case
Step 6 of 6
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Presentation
A 62-year-old man presents with breathlessness on exertion that has worsened over three months, now limiting him to one flight of stairs. He reports ankle swelling and needs two pillows to sleep. He has a history of hypertension and type 2 diabetes.
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Examination
Pulse 96 per minute, regular. Blood pressure 128/78 mmHg. Raised jugular venous pressure, fine bibasal crackles and pitting oedema to the mid-shins.
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Investigations
ECG shows sinus rhythm with Q waves in the anterior leads. Echocardiography shows a dilated left ventricle with an ejection fraction of 30% and anterior wall hypokinesia. Natriuretic peptide is markedly raised; kidney function is preserved.
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Question
How would you confirm the cause of his heart failure, and how would you begin treatment?
Think it through before you continue.
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Discussion
The findings are consistent with heart failure with reduced ejection fraction, and the regional wall-motion abnormality suggests an ischaemic cause, which should be evaluated. Congestion is treated with a diuretic, and guideline-directed medical therapy is started and titrated according to current guidelines, with monitoring of kidney function and potassium.
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Learning points
Regional wall-motion abnormalities point towards an ischaemic aetiology. Start disease-modifying therapy early rather than waiting for symptoms to settle. Reassess ejection fraction after optimisation before deciding on device therapy.
You've reached the end of this case.
Educational content for healthcare professionals. Always refer to the full guideline and use clinical judgement. Medical disclaimer
