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Old 06-24-2011
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Question dyspnea on exertion case

A 78-year-old white woman sees her cardiologist to discuss the findings of an echocardiogram performed yesterday. The patient originally sought medical advice regarding shortness of breath with vigorous exertion and intermittent swelling of her ankles. She has no history of other serious illness. The results of the echocardiogram show an ejection fraction of 45%. To help determine an appropriate therapy, the physician determines that the patient has no limitation of activities and suffers no symptoms from ordinary activities. Which of the following is the most appropriate pharmacotherapeutic regimen for this patient?

Answer Choices
A. Carvedilol, Lisinopril, Furosemide and Spironolactone and diltiazem
B. Enalapril, Furosemide and Spironolactone
C. Lisinopril, Metolazone and Carvedilol
D. Metolazone, Metoprolol succinate Spironolactone, Enalapril and Digoxin
E. Metoprolol succinate and Enalapril
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Old 06-25-2011
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I choose B.

My reasons are-

ACEI has proven benefit in heart failure.

Needs diuretics because of pedal oedema.

This is NYHA class 1!
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Originally Posted by 1TA2B View Post
I choose B.

My reasons are-

ACEI has proven benefit in heart failure.

Needs diuretics because of pedal oedema.

This is NYHA class 1!
no class 3
dypnea in mild exercise
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Quote:
Originally Posted by miss patho View Post
no class 3
dypnea in mild exercise
No limitation of daily activity is the key statement.

In class-3 marked limitation of normal daily activity.

NOT even class-2 either - because there's a component of limitation of daily activity.

This patient has breathlessness on exertion like running for bus! But the symptom does'nt limit his/her activity like washing/dressing/eating etc. So class-1!



http://en.wikipedia.org/wiki/New_Yor...Classification
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Old 06-25-2011
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i would go for E
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Option D (Metolazone, Metoprolol succinate Spironolactone, Enalapril and Digoxin) is correct. CHF Class III patients have no limitation of activities and suffer no symptoms from ordinary activities. The recommended therapy is a diuretic, ACE inhibitor, beta-adrenergic blocking agent, and aldosterone antagonist. Digoxin is also an appropriate medication.

Option A (Carvedilol, Lisinopril, Furosemide and Spironolactone and diltiazem) is incorrect. The recommended regimen for congestive heart failure (CHF) Class III patients. The recommended therapy is a diuretic, ACE inhibitor, beta-adrenergic blocking agent, and aldosterone antagonist. Calcium channel blocking agents are contraindicated in CHF.

Option B (Enalapril, Furosemide and Spironolactone) is incorrect. Patients with no limitation of activities and who are suffering no symptoms from ordinary activities are classified as having Class III CHF. The recommended therapy is a diuretic, ACE inhibitor, beta-adrenergic blocking agent, and aldosterone antagonist. A beta-adrenergic blocking agent should be added to the regimen.

Option C (Lisinopril, Metolazone and Carvedilol) is incorrect. The recommended therapy for patients with Class III CHF is a diuretic, ACE inhibitor, beta-adrenergic blocking agent, and aldosterone antagonist. This regimen lacks an aldosterone antagonist.

Option E (Metoprolol succinate and Enalapril) is incorrect. An ACE inhibitor, beta-adrenergic blocking agent, and aldosterone antagonist is the recommended therapy for Class III CHF. This regimen lacks a diuretic and an aldosterone antagonist.

High-yield Hit 1
CLASSIFICATION
The American College of Cardiology and the American Heart Association describe the following four stages of heart failure:
At high risk for heart failure, but without structural heart disease or symptoms of heart failure (e.g., CAD, hypertension)
Structural heart disease but without symptoms of heart failure
Structural heart disease with prior or current symptoms of heart failure
Refractory heart failure requiring specialized interventions
The New York Heart Association (NYHA) defines the following functional classes:
Asymptomatic
Symptomatic with moderate exertion
Symptomatic with minimal exertion
Symptomatic at rest

Taken from Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 2
TREATMENT OF CHF SECONDARY TO SYSTOLIC DYSFUNCTION:
Diuretics: indicated in patients with systolic dysfunction and volume overload. The most useful approach to selecting the dose of, and monitoring the response to, diuretic therapy is by measuring body weight, preferably daily.
Furosemide: 20 to 80 mg/day produces prompt venodilation and diuresis. IV therapy may produce diuresis when oral therapy has failed; when changing from IV to oral furosemide, doubling the dose is usually necessary to achieve an equal effect.
Thiazides are not as powerful as furosemide but are useful in mild to moderate CHF.
The addition of metolazone to furosemide enhances diuresis.
Blockade of aldosterone receptors by spironolactone (12.5 to 25 mg qd) used in conjunction with ACE inhibitors reduces both mortality and morbidity in patients with severe CHF. It is generally not associated with hyperkalemia when used in low doses, however, serum electrolytes and renal function should be closely monitored after initiation of therapy and when changing doses. Spironolactone use should be considered in patients with recent or recurrent class IV (NYHA) symptoms.
Frequent monitoring of renal function and electrolytes is recommended in all patients receiving diuretics.
ACE inhibitors:
They cause dilation of the arteriolar resistance vessels and venous capacity vessels, thereby reducing both preload and afterload.
They are associated with decreased mortality and improved clinical status when used in patients with CHF caused by systolic dysfunction. They are also indicated in patients with ejection fraction <40%.
They can be used as first-line therapy or they can be added to diuretics in patients with CHF poorly controlled with only diuretic therapy.
Therapy with ACE inhibitors should be initiated at low dose (e.g., captopril 6.25 mg tid or enalapril 2.5 mg bid) to prevent hypotension and rapidly titrated up to high doses if tolerated.
Contraindications to use of ACE inhibitors are renal insufficiency (creatinine >3.0 or creatinine clearance <30 ml/min), renal artery stenosis, persistent hyperkalemia (K+ >5.5 mEQ/L), symptomatic hypotension, and history of adverse reactions (e.g., angioedema).
β-blockers: All patients with stable NYHA class II or III heart failure caused by left ventricular systolic dysfunction should receive a β-blocker unless they have a contraindication to its use or are intolerant to it. β-blockers are especially useful in patients who remain symptomatic despite therapy with ACE inhibitors and diuretics. Effective agents are carvedilol (Coreg) 3.125 mg bid, bisoprolol 1.25 mg qd, or metoprolol 12.5 mg bid initially, titrated upward as tolerated.
Angiotensin II receptor blockers (ARBS) block the A-II type 1 (AT) receptor, which is responsible for many of the deleterious effects of angiotensin II. These receptors are potent vasoconstrictors that may contribute to the impairment of LV function. ARBS are useful in patients unable to tolerate ACE inhibitors because of angioedema or intractable cough. They can also be used in combination with a β-blocker.
Digitalis may be useful because of its positive inotropic and vagotonic effects in patients with CHF secondary to systolic dysfunction; it is of limited value in patients with mild CHF and normal sinus rhythm. It is more beneficial in patients with rapid atrial fibrillation, severe CHF, or ejection fraction of <30%; it can be added to diuretics and ACE inhibitors in patients with severe CHF. In patients with chronic heart failure and normal sinus rhythm, digoxin does not reduce mortality, but it does reduce the rate of hospitalization both overall and for worsening heart failure. Digoxin has a narrow therapeutic window. Its beneficial effects are found with a low dose that results in a serum concentration of approximately 0.7 ng/ml. Higher doses may be detrimental.
Direct vasodilating drugs (nesiritide, hydralazine, isosorbide) are useful in the therapy of systolic dysfunction with CHF because they can reduce the systemic vascular resistance and pulmonary venous pressure, especially when used in combination. Nesiritide (Natrecor), a recombinant human brain, or B-type, natriuretic peptide has venous, arterial, and coronary vasodilatory properties that decrease preload and afterload and increase cardiac output without direct inotropic effects. In hospitalized patients with acutely decompensated CHF, the addition of IV nesiritide to standard care improves hemodynamic function (decreased PCWP) and self-reported symptoms more effectively than IV nitroglycerin. Usual nesiritide dosage is 2 mcg/kg IV bolus, then 0.01 mcg/kg/min.
Anticoagulants:
Anticoagulation is not recommended for patients in sinus rhythm and no prior history of stroke, left ventricular thrombi, or arteriolar emboli.
Anticoagulation therapy is appropriate for patients with heart failure and atrial fibrillation or a history of embolism.
Surgical revascularization should be considered in patients with both heart failure and severe limiting angina.
Antiarrhythmic therapy with amiodarone has a modest effect in reducing mortality in patients with CHF; however, it is not recommended for general use in CHF. Its benefits must be weighed against the risk for adverse effects, especially potentially fatal pulmonary toxicity.
Atriobiventricular pacing significantly improves exercise tolerance and quality of life in patients with chronic heart failure and intraventricular conduction delay.
Obstructive sleep apnea has an adverse effect on heart failure. Recognition and treatment of coexisting obstructive sleep apnea by continuous positive airway pressure reduces systolic blood pressure and improves left ventricular systolic function.
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Old 06-25-2011
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Originally Posted by 1TA2B View Post
No limitation of daily activity is the key statement.

In class-3 marked limitation of normal daily activity.

NOT even class-2 either - because there's a component of limitation of daily activity.

This patient has breathlessness on exertion like running for bus! But the symptom does'nt limit his/her activity like washing/dressing/eating etc. So class-1!



http://en.wikipedia.org/wiki/New_Yor...Classification

The New York Heart Association (NYHA) defines the following functional classes:
1 Asymptomatic
2 Symptomatic with moderate exertion
3 Symptomatic with minimal exertion
4 Symptomatic at rest
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Originally Posted by miss patho View Post
The New York Heart Association (NYHA) defines the following functional classes:
1 Asymptomatic
2 Symptomatic with moderate exertion
3 Symptomatic with minimal exertion
4 Symptomatic at rest
What a difference from what I've known!

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Old 06-25-2011
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I to had also relied on the same scale that 1TA2b used so i did a search to find out heres what i found


Classification of Functional Capacity and Objective Assessment

In 1928 the New York Heart Association published a classification of patients with cardiac disease based on clinical severity and prognosis. This classification has been updated in seven subsequent editions of Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels (Little, Brown & Co.). The ninth edition, revised by the Criteria Committee of the American Heart Association, New York City Affiliate, was released March 4, 1994. The classifications are summarized below.
Functional Capacity

Class I. Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain.

Class II. Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.

Class III. Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.

Class IV. Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.

Objective Assessment

A - No objective evidence of cardiovascular disease
B - Objective evidence of minimal cardiovascular disease
C - Objective evidence of moderately severe cardiovascular disease
D - Objective evidence of severe cardiovascular disease

=====
So according to the functional scale shes a class 1 ( key point dyspnea with VIGOROUS excersize) and according to the objective scale i wouldnt really be able to say but the low ejection fraction makes me think C

Last edited by docnas; 06-25-2011 at 01:17 PM.
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