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Old 10-19-2011
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Default Cardiology

A 65-year-old man with ischemic cardiomyopathy is complaining of increasing shortness of breath. He denies medical or dietary noncompliance. He is on appropriate medications and at maximal doses. He denies recent illness. He has no chest pain, lightheadedness, fever, chills, or shakes. He has no palpitations. His vital signs are stable. He has bilateral crackles. Cardiac examination reveals an S3. Jugular venous pressure is 13 cm of water. He has pedal edema. Echocardiogram reveals stable ejection fraction at 30%. Laboratory studies are normal. Electrocardiogram reveals a left bundle branch block. Which of the following is the appropriate management?
*********** A. ****** Administer oxygen****
*********** B. ****** Perform a left heart catheterization***
*********** C. ****** Place on a dobutamine drip***
*********** D. ****** Refer for a biventricular pacemaker***
*********** E. ******* Refer for cardiac transplantation***
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Old 10-19-2011
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Originally Posted by drnrpatel View Post
A 65-year-old man with ischemic cardiomyopathy is complaining of increasing shortness of breath. He denies medical or dietary noncompliance. He is on appropriate medications and at maximal doses. He denies recent illness. He has no chest pain, lightheadedness, fever, chills, or shakes. He has no palpitations. His vital signs are stable. He has bilateral crackles. Cardiac examination reveals an S3. Jugular venous pressure is 13 cm of water. He has pedal edema. Echocardiogram reveals stable ejection fraction at 30%. Laboratory studies are normal. Electrocardiogram reveals a left bundle branch block. Which of the following is the appropriate management?
*********** A. ****** Administer oxygen****
*********** B. ****** Perform a left heart catheterization***
*********** C. ****** Place on a dobutamine drip***
*********** D. ****** Refer for a biventricular pacemaker***
*********** E. ******* Refer for cardiac transplantation***
B. Perform a left heart catheterization ??
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Old 10-19-2011
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D. ****** Refer for a biventricular pacemaker
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Old 10-19-2011
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E). refer for a cardiac transplant
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Old 10-19-2011
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i would say D as EF less than 35 and already on optimal medical management!!!
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Old 10-19-2011
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Correct Answer Answer

The correct answer is D. The MUSTIC and MIRACLE trials were concluded recently and showed morbidity improvement with biventricular pacing, in which a lead was placed in the right ventricle and over the left ventricle through a cardiac vein. This reduces the asynchrony and enhances cardiac function. This patient is on maximal medicines and should be considered for biventricular pacing.

Oxygen may alleviate symptoms somewhat, but the patientís vital signs are stable (choice A).

The patient has no chest pain, and a left heart catheterization unnecessarily exposes him to risk (choice B).

If the pacemaker placement does not help the patient, a dobutamine drip to improve cardiac output would be a helpful temporizing approach (choice C).

This patient may be considered for transplantation if all other efforts prove unsuccessful (choice E).
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Old 10-19-2011
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[QUOTE=drnrpatel;74169]The correct answer is D. The MUSTIC and MIRACLE trials were concluded recently and showed morbidity improvement with biventricular pacing, in which a lead was placed in the right ventricle and over the left ventricle through a cardiac vein. This reduces the asynchrony and enhances cardiac function. This patient is on maximal medicines and should be considered for biventricular pacing.


r we supposed to know all these different trials for ck?? if yes r they covered up in kaplan or MTB...hav jst strtd prep for ck so dnt kno abt it..i jst kno a little abt RALES trial...
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Old 10-19-2011
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^^Not exactly.(Not possible too)..

Here in this question there are signs of Right and Left Heart failure.
Rt-Pedal Edema and Raised JVP
Lt-Crackles.
So logically Biventricular Pacing is needed.
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