(c)A detailed personal/social history
(d)Substitution of allopurinol for the meclofenamate
(e)Hold the bendroflumethiazide temporarily and start
an ACE inhibitor
(f) Start bezafibrate.Answer(a)False
(b)False
(c)True
(d)False
(e)True
(f) False.Comment
The aetiology of the heart failure in this case is uncertain.
Although ischaemia and hypertension may be playing a
part, the diffusely poorly contracting myocardium suggests
the possibility of diffuse cardiomyopathy, and the raised
γ-glutamyltranspeptidase and triglyceride levels point to
the possibility of alcohol excess. If this is the case, and if it is
corrected, this could improve the blood pressure, dyslipi-
daemia and gout, as well as cardiac function. In the long
term, allopurinol should be substituted for the NSAID, but if
done immediately this is likely to precipitate an acute
attack. Aspirin should be taken (for its antiplatelet effect,
which may not be shared by all other NSAIDs). Treatment
with a fibrate would be useful for this pattern of dyslipi-
daemia, but only after establishing that it was not alcohol-
induced.216 HEART FAILURE
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