Worsening Heart Failure Symptoms — Free SCA Practice Case
Woman with worsening heart failure symptoms
Station Timer
12:00
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
12:00
Golden MinuteFive cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Margaret Hale
Age
74 years
Consultation Type
TelephoneAge
74
Situation
Telephone Consultation.
Reason for Encounter
"Breathing has been getting worse over the last two weeks. Finding it hard to get up the stairs."
Medical Records
- ●PMH: Heart Failure with Reduced Ejection Fraction (HFrEF) - diagnosed 3 years ago following an MI. Last Echo (6 months ago): LVEF 40%.
- ●PMH: Osteoarthritis (Knees), Hypertension.
- ●Medications: Ramipril 5mg BD, Bisoprolol 2.5mg OD, Furosemide 40mg OD, Atorvastatin 20mg OD.
- ●Recent Notes:
- ●3 Months Ago: Heart failure review. Stable. NYHA Class II (mild limitation). U&Es: Sodium 138, Potassium 4.5, Creatinine 95 (eGFR 58).
Patient Script
For the friend playing the patient role
Character Overview: You are Margaret. You are generally a cheerful, active grandmother who hates "fuss." You pride yourself on managing your condition well. You are confused because you haven't missed any heart tablets, yet you feel like you're "filling up" with water again.
Opening Sentence: "Hello Doctor. I'm sorry to bother you, but my breathing isn't right. For the last fortnight, I've been getting so puffed just walking to the kitchen. My ankles are swollen too—I can't get my normal shoes on."
A. History if Asked (Data Gathering Phase)
- ●Symptoms of Decompensation:
- ●Exertion: "I used to manage the stairs fine. Now I have to stop halfway."
- ●Orthopnoea: "I've had to add an extra pillow this week, so I'm sleeping on three now. I feel a bit like I'm drowning if I lie flat."
- ●PND: "I woke up once two nights ago gasping for air. It was frightening."
- ●Weight: "I haven't weighed myself, but my skirts feel tight around the waist."
- ●The "Hidden" Precipitant (The NSAID Trap):
- ●If asked about new medications or painkillers: "Well, my knees have been playing up with this damp weather. My daughter bought me some Nurofen (Ibuprofen) from the chemist about two weeks ago. They've been marvelous for the pain! I've been taking two, three times a day."
- ●Note: You do not realise these are bad for your heart. You think they are just standard painkillers.
- ●Red Flags:
- ●No chest pain (angina).
- ●No palpitations or dizziness.
- ●No fever or cough (ruling out infection).
ICE — Ideas, Concerns, Expectations
The patient does not volunteer any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective.
- ●Ideas: "I honestly don't know why it's got worse — I haven't missed a single tablet. I thought maybe I'd picked up a bug or something, or maybe the heart is just getting tired. I can't think what else it could be."
- ●Concerns: "I suppose I'm worried that this means the heart is getting worse for good. After the heart attack three years ago, they said I'd have to be careful. I don't want to end up in hospital again — I was in for nearly two weeks last time and it frightened the life out of me."
- ●Expectations: "I just want to feel like I did a few weeks ago — I was managing fine then. If you can give me something to shift this fluid and help me breathe properly again, that's all I'm asking. I don't want a fuss, I just want to get back to normal."
If Asked — Medical History and Medications
The patient responds to direct questions about her medical history and medications as follows. She is generally well-informed about her conditions but understands them in lay terms.
- ●Heart failure / heart attack: "Yes, I had a heart attack about three years ago. They said the heart muscle was damaged and it doesn't pump as strongly as it should. I've been under the hospital for it — had the scan about six months ago and they said it was stable, but keep taking everything."
- ●Ramipril: "That's one of my heart tablets — I take it morning and night. I've been on it since the heart attack. No problems with it."
- ●Bisoprolol: "That's the one that slows the heart down, isn't it? I take it every morning. Never missed one."
- ●Furosemide: "That's my water tablet. One every morning. It does make me go to the loo a lot, but I'm used to it by now."
- ●Atorvastatin: "The cholesterol one — I take it at night. I've been on that for years."
- ●Recent heart failure review (3 months ago): "Yes, I saw the nurse about three months ago. She said everything was looking fine — bloods were good, I was managing well. She was pleased with me."
- ●Hypertension: "Yes, they keep an eye on my blood pressure. It's been alright recently as far as I know."
- ●Osteoarthritis: "My knees have been bad for years. It's worse in the cold and damp. That's why I started taking the Nurofen — the paracetamol just wasn't cutting it anymore."
Social History and Lifestyle Impact
Margaret volunteers this naturally in conversation when discussing her symptoms and their effect on her daily life. She does not deliver it as a monologue — it emerges through the flow of the consultation.
- ●Daily life: Margaret is a retired primary school teaching assistant. She lives alone in a two-storey terraced house since her husband died five years ago. Her daughter lives ten minutes away and visits most days. She is an active grandmother to two grandchildren (aged 4 and 7) and usually has them at her house twice a week.
- ●Lifestyle impact: "I've had to tell my daughter I can't have the little ones this week — I just can't keep up with them. Normally I'm chasing them round the garden, but right now I can't even get to the top of the stairs without stopping. I couldn't do the school run on Wednesday because I was too breathless walking up the hill. And I always do the weekly shop on a Thursday — I had to ask my daughter to go for me because I couldn't manage carrying the bags. It's knocked me sideways, really."
If Asked — Associated Symptoms
The patient responds to direct questions about associated symptoms as follows. Answers should be brief and natural.
- ●If asked about chest pain: "No, no pain in my chest — just the breathlessness."
- ●If asked about palpitations: "No, I don't feel my heart racing or anything like that."
- ●If asked about dizziness or feeling faint: "No, nothing like that. I just get puffed."
- ●If asked about cough: "No real cough. Maybe the odd little dry one when I'm lying down, but nothing to speak of."
- ●If asked about coughing up blood: "No, nothing like that at all."
- ●If asked about fever or feeling unwell: "No, I don't feel ill in myself — just this breathlessness and the swelling."
- ●If asked about leg swelling (beyond ankles): "It's mainly the ankles, but my calves feel a bit tight and puffy too, especially by the evening."
- ●If asked about pain or tenderness in the legs: "No real pain — just the swelling and a bit of heaviness."
- ●If asked about urine output: "Now you mention it, I don't think I've been going as often as usual, even with the water tablet. And it seems a bit darker."
- ●If asked about appetite: "I haven't felt as hungry this last week. I feel a bit bloated after eating, like there's no room."
- ●If asked about fatigue: "Oh yes, I'm shattered. Even little things tire me out at the moment. I had a nap yesterday afternoon and that's not like me at all."
- ●If asked about confusion or memory problems: "No, my head is fine — I know exactly what's going on, I just can't breathe properly."
- ●If asked about recent infections or illness: "No, I've been well otherwise. No colds or anything."
- ●If asked about dietary salt intake: "I don't add salt to my cooking — they told me not to after the heart attack. But I do like a packet of crisps with my tea sometimes."
- ●If asked about fluid intake: "I probably drink about five or six cups of tea a day, and some water. Nothing out of the ordinary."
- ●If asked about alcohol: "I might have a small sherry at the weekend, but that's about it."
- ●If asked about smoking: "Never smoked in my life."
B. Responses to Management (The Negotiation Phase)
- ●If the Doctor says stop the Ibuprofen:
- ●Reaction: "Oh really? But they are the only thing that touches the knee pain! Paracetamol doesn't do anything. What am I supposed to take instead?"
- ●If the Doctor wants to admit to hospital:
- ●Reaction: Reluctant. "Do I really have to? I've got my grandson's birthday party on Saturday. Can't we just increase the water tablets? I promise I'll rest."
- ●If the Doctor increases Furosemide:
- ●Reaction: "Will that make me go to the toilet all night? Can I take the extra one in the morning?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
0 / 16 indicators checked+0−0
Positive (0/8)
Negative (0/8)
Domain 2: Clinical Management and Medical Complexity
0 / 20 indicators checked+0−0
Positive (0/10)
Negative (0/10)
Domain 3: Relating to Others
0 / 12 indicators checked+0−0
Positive (0/6)
Negative (0/6)
Clinical Learning Points
1
Recognising Acute Decompensation of Heart Failure
- ●The cardinal symptoms of fluid overload are orthopnoea (needing extra pillows to sleep — fluid redistributes to the lungs when supine), paroxysmal nocturnal dyspnoea (waking from sleep gasping — caused by delayed fluid redistribution), bilateral peripheral oedema, and weight gain from fluid retention.
- ●Functional decline is the key marker of severity. Map the patient's current exercise tolerance against their known baseline and express this as an NYHA class shift — in this case, from Class II (mild limitation) to Class III–IV (marked limitation at minimal exertion or rest).
- ●Decompensation is rarely spontaneous. Always search systematically for a precipitant: new medication (especially OTC NSAIDs, steroids), dietary salt excess, medication non-adherence, intercurrent infection, new arrhythmia (particularly AF), or acute coronary syndrome.
2
The NSAID Trap in Heart Failure
- ●NSAIDs are contraindicated in severe heart failure per NICE CKS guidance, and should be used only with caution in mild to moderate heart failure. They cause sodium and water retention, impair renal function, and directly antagonise the effect of diuretics, all of which can precipitate acute decompensation. Where an NSAID is genuinely essential in mild to moderate heart failure, NICE CKS identifies low-dose ibuprofen (up to 1200mg daily) as the preferred option and low-dose naproxen as second choice. COX-2 inhibitors and high-dose ibuprofen should be avoided across all severities of heart failure.
- ●Topical NSAIDs carry significantly lower systemic absorption and are a reasonable alternative to consider, though caution remains appropriate in more advanced disease.
3
The "Triple Whammy" and Acute Kidney Injury Risk
- ●This patient is taking an ACE inhibitor (Ramipril) and a loop diuretic (Furosemide). Adding an NSAID creates the classic triple whammy combination: the diuretic reduces circulating volume, the ACE inhibitor dilates the efferent arteriole, and the NSAID constricts the afferent arteriole — the result is a severe drop in glomerular filtration rate and a high risk of AKI.
- ●Urgent U&Es are mandatory (within 48–72 hours) in any patient who has been taking this combination, even if clinically well. The increased furosemide dose further raises the AKI risk and is an additional reason to check renal function promptly.
- ●Reduced urine output and darkened urine — as described by this patient — are clinical signals that AKI may already be developing.
- ●Remember the acronym DAMN for drugs that worsen AKI: Diuretics, ACE inhibitors/ARBs, Metformin, NSAIDs.
4
Community Management of Decompensated HFrEF
- ●Hospital admission is indicated for: breathlessness at rest, oxygen saturations below 90%, new arrhythmia, haemodynamic compromise, or no reliable home support. In the absence of these features, community management with close monitoring is appropriate.
- ●Remove the precipitant first — stop the NSAID immediately. This alone may produce significant symptomatic improvement.
- ●Increase the diuretic dose to offload accumulated fluid — typically doubling the furosemide dose (e.g. 40 mg to 80 mg daily) for 3–5 days, with a clear plan to step back down once fluid is cleared.
- ●Daily weight monitoring is a practical and evidence-based self-management tool. Advise the patient to weigh each morning before breakfast and contact the surgery if weight increases by more than 2 kg over 2–3 days.
- ●Arrange telephone or face-to-face review within 48–72 hours to assess symptomatic response, review U&E results, and confirm the diuretic is being tolerated.
5
Safe Analgesia for Osteoarthritis in Heart Failure
- ●Do not stop the NSAID without offering an alternative — an unmanaged pain problem significantly increases the chance the patient will restart the NSAID.
- ●First line: Paracetamol at full therapeutic dose (1 g four times daily, up to 4 g/day) rather than as-needed low doses that fail to provide adequate analgesia.
- ●Topical preparations: Topical NSAID gel (e.g. topical diclofenac or ibuprofen gel) is a reasonable option given minimal systemic absorption; safer than oral NSAIDs in heart failure.
- ●Second line: Weak opioids (e.g. codeine or co-codamol) can be used for short-term breakthrough pain; counsel on constipation risk.
- ●Non-pharmacological: Physiotherapy referral, heat/cold application, weight optimisation, and intra-articular corticosteroid injection (delivered by the appropriate service) are all guideline-supported adjuncts for knee OA.
6
Heart Failure Medication Optimisation
- ●Acute decompensation is a prompt to review the adequacy of background HFrEF therapy — but optimisation should be planned for a stable follow-up appointment, not during an acute episode when fluid status and renal function are in flux.
- ●This patient's current regimen — Ramipril 5 mg BD and Bisoprolol 2.5 mg OD — may be below target doses. NICE and ESC guidance recommends uptitrating ACE inhibitors and beta-blockers to the maximum tolerated dose in HFrEF.
- ●She is not currently on a mineralocorticoid receptor antagonist (MRA) (e.g. spironolactone or eplerenone) or an SGLT2 inhibitor (e.g. dapagliflozin or empagliflozin). Both drug classes have a Class I recommendation in HFrEF and are associated with reduced mortality and hospitalisation. Their absence represents a significant optimisation opportunity.
- ●Consider liaison with or referral to the heart failure specialist nurse for ongoing community monitoring and medication titration support.
7
Referral and Escalation Criteria
- ●Arrange same-day emergency admission if the patient develops severe breathlessness at rest, new syncope, clinical deterioration suggesting cardiogenic shock, or oxygen saturations that are significantly reduced from baseline. These are not explicitly defined thresholds in NICE CG187 but reflect the clinical features of acute decompensation requiring inpatient care.
- ●If the patient's clinical condition is not improving, use a short monitoring timeframe of days to every 2 weeks in line with NICE NG106, and reassess the threshold for admission if symptoms are not settling, weight is not falling, or renal function is deteriorating.
- ●Following resolution of the acute episode, consider referral back to the specialist heart failure MDT if the patient's condition is not responding to treatment in primary care, if they have advanced heart failure (NYHA class III to IV), or if medicines requiring specialist supervision need to be initiated, including ARNI, in line with NICE NG106.
8
Safety-Netting for This Consultation
- ●Specific red flags requiring 999 activation: chest pain, severe breathlessness at rest, feeling faint or collapsing, lips or fingertips turning blue.
- ●Specific red flags requiring same-day GP contact: symptoms significantly worsening before the scheduled review, inability to pass urine, or weight increasing rapidly.
- ●Confirm the patient knows: (1) when and how to take the increased furosemide, (2) when and where to have blood tests, (3) when you will call to review, and (4) exactly what to do and who to call if any of the above occur. On a telephone consultation this explicit verbal summary — and asking the patient to repeat it back — is especially important given the absence of written information at the point of contact.
9
Common Candidate Mistakes in This Case
- ●Missing the NSAID precipitant by failing to ask specifically about over-the-counter medications. A medication history that only covers prescribed drugs is incomplete.
- ●Replacing ibuprofen with another oral NSAID (e.g. naproxen) — this is a class contraindication, not a drug-specific one.
- ●Stopping the NSAID without offering alternative analgesia — this almost guarantees the patient will restart it.
- ●Failing to arrange urgent U&Es — the triple whammy combination and increased diuretic dose both require renal monitoring within days, not weeks.
- ●Leaving the diuretic dose unchanged despite clear evidence of fluid overload — inadequate treatment of the acute episode.
- ●Vague safety-netting ("call if worse") without specifying which symptoms warrant what action and over what timeframe.
Further reading
From the PCCS Academy, the Primary Care Cardiovascular Society’s learning modules for primary care.
Free for practising healthcare professionals. You need a PCCS account to open these. Join the PCCS
Mapped to the RCGP curriculum topic: Cardiovascular Health.
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