CHF with AF why not beta blockers instead of digoxin! - USMLE Forums
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  #1  
Old 06-07-2011
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Heart CHF with AF why not beta blockers instead of digoxin!

A question is the following:

A 71-year-old man comes to his physician for follow-up of a recent emergency department visit. The patient has a 2-year history of mild congestive heart failure in the setting of long-standing hypertension. He reports that yesterday he sought care at the local emergency department for palpitations and shortness of breath. He was told that his heart was "fibrillating", but later, the fibrillation had "stopped on its own." His medications include a thiazide diuretic and an ACE inhibitor. On physical examination, he appears well and in no distress. His blood pressure is 130/80 mm Hg, and his pulse is 100/min and regular. His lungs have scant bibasilar rales, and no gallops are appreciated. He has a grade 2 holosystolic murmur heard best at the apex. His jugular venous pressure (JVP) is 10 cm at 30 degrees. An electrocardiogram taken in the office reveals atrial fibrillation at a rate of 94/min with normal ST segments. Which of the following is the most appropriate next step in management?

A. Discontinue the ACE inhibitor
B. Initiate amiodarone therapy
C. Initiate beta blocker therapy
D. Initiate digoxin therapy
E. Initiate furosemide therapy

------------------------

The answer provided is

he correct answer is D. An important concept to recognize in the treatment of medical conditions is that certain medications overlap syndromes and are efficacious in many areas. This "co-treatment" option maximizes the benefits of each drug in a regimen and often addresses two or more issues simultaneously. In this case, ACE inhibitors have been shown to be very beneficial in prolonging the survival of patients with congestive heart failure (CHF). They are also useful antihypertensive agents. Given this, discontinuing his ACE inhibitor (choice A) is clearly incorrect. This patient requires rate control for his atrial fibrillation, that, even at moderately elevated rates, causes cardiovascular embarrassment and pulmonary edema. Short of restoring this patient's atrial contractions, rate control is the best method to ensure adequate management of atrial fibrillation. Digoxin, with or without a nodal agent such as a beta blocker, has been shown to be reasonably effective at rate control.

Amiodarone therapy (choice B) is a pharmacologic method to convert atrial fibrillation to normal sinus rhythm. It has about the same efficacy as electrical cardioversion. It does nothing, however, in the short term, to control the rate.

Beta blocker therapy (choice C) alone is not as efficacious as digoxin alone. In addition, although some beta blockers (carvedilol) are being used clinically in CHF, not all beta blockers have been shown to be safe for use with this condition. Therefore, although digoxin plus a beta blocking agent would be preferred, there is good reason to initiate digoxin therapy alone for this patient.

Furosemide therapy (choice E) is partially correct. Although furosemide will help clinically with the failure, the underlying cause for the pulmonary edema will not be addressed solely by giving a diuretic. The more appropriate therapy is to control the rate, then the edema will resolve.

--------------
I am arguing that the answer is wrong, and that b-blocker is definitely a better choice!!! lowers mortality as well!!! why didnt they choose it?!?!??
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  #2  
Old 06-07-2011
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Heart

I would have thought BB as well. However according to UpToDate: "Rate control in AF is usually achieved by slowing AV nodal conduction with a beta blocker, diltiazem, verapamil, or, in patients with heart failure or hypotension, digoxin."
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but why?????????

Do we not use beta blocker for patients with CHF symptoms? why not use it with AF if it works with it ....


is it because "r. His lungs have scant bibasilar rales," and thus beta blocker might worsen the pulmonary edema?

i feel as if i dont know anything ... and my exam is in 20 days ...
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Originally Posted by docoftheworld View Post
but why?????????

Do we not use beta blocker for patients with CHF symptoms? why not use it with AF if it works with it ....


is it because "r. His lungs have scant bibasilar rales," and thus beta blocker might worsen the pulmonary edema?

i feel as if i dont know anything ... and my exam is in 20 days ...
I assume that digoxin is used for a-fib in CHF because of the added benefit of increased contractility, which would improve the symptoms of CHF.

It seems similar to the manner in which antihypertensives are chosen based on the patient's comorbidities and the additional medical benefits of the various antihypertensives.
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i hope my ignorance of that fact does not mean i will not do well in the test ... im tense
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Originally Posted by docoftheworld View Post
i hope my ignorance of that fact does not mean i will not do well in the test ... im tense
just relax...since anyone can perform good only under minimal pressure...as per quest person seems to be in nyh class 3 stage and sympt decompensated hf...so bb is clearly contraindicated...see contraindications of bb.....so digoxin is the choice
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hi confident ... i was thinking the same: perhaps acutely decompensated CHF should never get BB (same should apply to acuetly infarcting heart i think, no? ...
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Originally Posted by docoftheworld View Post
hi confident ... i was thinking the same: perhaps acutely decompensated CHF should never get BB (same should apply to acuetly infarcting heart i think, no? ...
If there is acutely infarcting heart with acute CHF, BB is a big no no.......but if there is NO acutely developing CHF, BB are definitely added since they r both anti-ischemic and anti-arrhythmic.

Also, just to add up regarding the question, BB decrease the contractilty of the heart and that we dont want in heart failure, since it would worsen it.
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Old 06-08-2011
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Brother,
the answer is right
for rate control there are two stratigies
one is to initiate and the other is to maintain
given this case, who has paroxysmal AF (not choronic) + having CHF which is commonly excerebrated by the AF and is then a big issue, controlling the rhythm fast by digoxin is recommended and then stabilizing the effect by Beta blockers
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Originally Posted by alaahoda2001 View Post
Brother,
the answer is right
for rate control there are two stratigies
one is to initiate and the other is to maintain
given this case, who has paroxysmal AF (not choronic) + having CHF which is commonly excerebrated by the AF and is then a big issue, controlling the rhythm fast by digoxin is recommended and then stabilizing the effect by Beta blockers
Adding to the answer above i want to point your attension to that the cause of not PREFERING to use BB was not because of decompansation because it is clearly said that the patient in the SECOND VISIT "looks well and is not distressed"
so at that time BB would be actually reasonable
The best treatment actually is Digoxin + BB but there is not such a choice in the answers and then we have to chose the thing that initiates the therapy (THE BEST NEXT STEP) and that despite of having some basal rales means that he is not in a state of acute failure
Another thing, Digoxin is not used here for a contractility benifit what so ever because the proble is not in contractility now (NOT IN FAILURE) but the problem is in the rate
Note that it is clear that the first attack of symptoms were clearly a decompansated HF precipitated by AF (So the proble is AF and it must be dealt with effectively and fast)
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Originally Posted by alaahoda2001 View Post
Adding to the answer above i want to point your attension to that the cause of not PREFERING to use BB was not because of decompansation because it is clearly said that the patient in the SECOND VISIT "looks well and is not distressed"
so at that time BB would be actually reasonable
The best treatment actually is Digoxin + BB but there is not such a choice in the answers and then we have to chose the thing that initiates the therapy (THE BEST NEXT STEP) and that despite of having some basal rales means that he is not in a state of acute failure
Another thing, Digoxin is not used here for a contractility benifit what so ever because the proble is not in contractility now (NOT IN FAILURE) but the problem is in the rate
Note that it is clear that the first attack of symptoms were clearly a decompansated HF precipitated by AF (So the proble is AF and it must be dealt with effectively and fast)
yes patient is not under distress right now but..its only 2 days since he recovered from unstable to stable....so patient falls under which stage of nyh classification?..1. so after 2 days of attack can we give digoxin+bb
2. can digoxin+bb used for long term treatment option
3. what is the present condition of patient: follow up, which stage of nyh, stable or unstable
4. what are different presentation and treatment option of CHF+AF
..can some one plz take time and explain patiently....it will be very helpful
thanks
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Quote:
Originally Posted by confident View Post


yes patient is not under distress right now but..its only 2 days since he recovered from unstable to stable....so patient falls under which stage of nyh classification?..1. so after 2 days of attack can we give digoxin+bb
2. can digoxin+bb used for long term treatment option
3. what is the present condition of patient: follow up, which stage of nyh, stable or unstable
4. what are different presentation and treatment option of CHF+AF
..can some one plz take time and explain patiently....it will be very helpful
thanks
Having symptoms of HF 2 days ago do not necessarly mean that the patient is in decompansation now
the most important sign of decompnsated HF (Despite not the only) is dyspnea (1- On effort 2- On lying flat i.e. Orthopnea, 3- Waking the patient from sleep i.e. PND) the patient is said not to be distressed i.e. no Dyspnea
having digoxin to plus BB for the long term, despite not exclusively contraindicated but is not the best option
the patient should idealy start on Digoxin and low dose BB until controlling the rate then stop digoxin and continue on the BB with titrating up the dose as maintenance therapy

However, Digoxin can be used in patients with HF as a long term therapy as it was shown to decrease symptoms and repeated hospitalization (NOT MORTALITY)
I will explain in a later post about AF and CHF

C u and God bless
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