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Old 10-19-2011
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Default Cardiology

A 48-year-old man complains of shortness of breath with exertion and increasing leg edema. He is given a diagnosis of congestive heart failure. Extensive diagnostic studies reveal no evidence of heart disease. However, his echocardiogram reveals an ejection fraction of 25%. Given this diagnosis of idiopathic dilated cardiomyopathy, he is advised to consume a low-sodium diet and start lisinopril, digitoxin, and furosemide. His shortness of breath improves, but he continues to feel fatigued. On examination, his heart rate is 85/min and blood pressure is 105/70 mm Hg. His lungs are clear. His cardiac examination reveals an S4. His exercise stress test at a low-level protocol reveals his ability to walk for 6 minutes. His heart rate increases to 130/min; blood pressure rises to 140/70 mm Hg. However, his peak oxygen uptake is at 15 mL/kg/min. Which of the following is the most appropriate management?
A. He should avoid any activity
B. He should start a closely monitored exercise regimen
C. He should minimize all activity
D. He should adjust his activity to avoid fatigue
E. He should limit his activity until his cardiac status is stabilized
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Old 10-19-2011
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B. He should start a closely monitored exercise regimen
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Old 10-20-2011
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C..he should minimise all activity??
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B. He should start a closely monitored exercise regimen
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Default Answer

The correct answer is B. This patientís oxygen uptake is limited and his blood pressure rose during exercise, which indicates that his fatigue is the result of deconditioning. The patient has been optimized medically. Thus, physical activities should be encouraged, not avoided. Rehabilitation programs for patients with heart failure have successfully improved functional ability with acceptable risk. Such activity improves oxygen uptake, muscle preservation, and the patientís sense of well-being.

Avoiding any activity (choice A) will simply worsen the patientís conditioning and cause skeletal muscle wasting. Thus, choosing no activity will prevent this patient from obtaining the benefit of cardiac rehabilitation.

Minimizing activity (choice C) may seem a good compromise between avoiding any activity and conducting physically challenging activities. However, the minimum amount of exercise needed to gain the benefits in functional capacity has not been determined.

Adjusting activity to avoid fatigue (choice D) could be very limiting for this patient. The exercise stress test can provide initial guidance. The patient should undertake aerobic exercise of 20 minutes a day, three times a week. He can then increase his regimen as tolerated.

The patientís cardiac status is currently stabilized (choice E). Thus, he should be encouraged to increase his activity as tolerated.
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