A 75-year-old man presented with bilateral ankle edema and shortness of breath on exertion. He had a past medical history of hypertension, diabetes mellitus, atrial fibrillation, coronary heart disease and congestive heart failure. He had been admitted to the hospital because of heart failure for four times in the last year. His blood pressure and pulse rate were 130/70mmHg and 85bpm, respectively. The chest X-ray showed features of cardiomegaly and pulmonary congestion. Transthoracic echocardiogram in the last hospital admission revealed impaired left ventricular ejection fraction of 30%.

The patient had no known drug allergies. His medications included lisinopril 20mg daily, metoprolol succinate 25mg daily, frusemide 40mg daily, aspirin 80mg daily, pantoprazole 40mg daily, warfarin 3mg daily and gliclazide 80mg bd.

a) Suggest THREE drug classes with examples as the add-on treatment for patient with stage C heart failure with reduced ejection fraction which have benefits on survival and prevention of hospitalization. List the mechanism of action, beneficial effects, adverse effects and contraindications of each drug class. (12 marks)

b) A doctor wanted to add flecainide and rosiglitazone for management of atrial fibrillation and diabetes mellitus for the patient. Discuss why these two medications were considered potentially inappropriate. (2 marks)

c) Which oral hypoglycaemic drug class may be beneficial to the patient with severe heart failure, and why? What are the risks associated with the use of this oral hypoglycaemic agent? (3 marks)

d) After heart failure medication optimization, discuss THREE pharmacist interventions which are associated with improvement in patient’s heart failure outcome during hospital discharge period. (3 marks)