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Old 10-20-2011
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Default Cardiology

In the emergency room, you are seeing a 55-year-old man who complains of increased shortness of breath and increasing lower extremity swelling for the past 10 days. The patient is well known to the emergency room staff for frequent admissions for “fluid overload.” The patient has a history of coronary artery disease, hypertension, non–insulin-dependent diabetes, and was a former smoker of 2 packs per day for 30 years. The patient had a myocardial infarction 3 years ago, underwent urgent cardiac catheterization, and had a stent placed to the left anterior descending artery. He is currently being treated with a beta-blocker, an ACE inhibitor, furosemide BID, and aspirin. Since the patient’s myocardial infarction, he denies any further chest pain but has had multiple episodes of congestive heart failure. At baseline the patient can walk three to four blocks before becoming short of breath, and he has two-pillow orthopnea. His vital signs are: blood pressure 140/60 mm Hg, pulse 92/min, respirations 22/min, temperature 37 C (98.6 F); and O2 saturation on 4 L nasal cannula is 99%. Physical examination shows a mild increase in jugular venous pressure, crackles at the lung bases bilaterally, a regular rhythm with an S3 gallop, and 3+ pitting edema to below the knees. Electrocardiogram shows a left bundle branch block (old compared with previous electrocardiogram) and chest x-ray shows pulmonary vascular congestion with cephalization. You learn from the old chart that the patient’s last echocardiogram, done 8 months ago, showed a severely decreased ejection fraction of 20% with anterior/apical wall hypokinesis. Which of the following additional therapies should be offered to this patient to further decrease his mortality before discharge from the hospital?
A. Amlodipine, orally, once daily
B. Digoxin, orally, once daily
C. Implantable cardioverter-defibrillator
D. Isosorbide dinitrate, orally, once daily
E. Warfarin, orally, at bedtime
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Old 10-21-2011
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E. Warfarin, orally, at bedtime
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E. Warfarin, orally, at bedtime
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C. Implantable cardioverter-defibrillator
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Old 10-21-2011
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C. Implantable cardioverter-defibrillator
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Default Answer

The correct answer is C. Systolic heart failure is a complex clinical syndrome that has become the leading cause of hospitalization for people older than 55 years as more people are surviving myocardial infarcts and living longer. Systolic heart failure is characterized by impaired left ventricular systolic function that leads to both activation of the neuroendocrine renin-angiotensin-aldosterone axis and circulatory congestion. The most common cause of congestive heart failure (CHF) is ischemic heart disease followed by hypertensive heart disease (often associated with diastolic heart failure), valvular disease, and various cardiomyopathies. This patient presents with the most common clinical findings of a CHF exacerbation, including increased jugular venous distension (JVD), pulmonary rales, an S3 heart gallop, and peripheral edema.

Several effective treatments have repeatedly been shown to decrease mortality in patients with CHF. These include ACE inhibition (CONSENSUS, SOLVD trials), and the use of beta-blockers (MERIT and the U.S. Carvedilol Studies). Diuretics, such as furosemide, although never shown to lower mortality, should be part of a standard regimen to help maintain euvolemia. In addition to the therapies named above it has been shown that the implantation of an ICD (implantable defibrillator) reduced mortality in patients with ischemic heart disease and an ejection fraction of less than 30 by 31% (MADIT 2 trial). The rationale behind the increased use of an ICD is patients with reduced ventricular function after an MI are at increased risk for life-threatening ventricular arrhythmias. Several randomized trials have shown that electrical therapy with ICD is superior to medical therapy in both primary and secondary prevention of sudden cardiac death in patients with reduced left ventricular function. However, patients with ischemic cardiomyopathy showed improved survival, while the data from patients nonischemic cardiomyopathy was not as convincing.

Calcium channel blockers (choice A), including the dihydropyridines such as amlodipine and nifedipine, are potent blood pressure–lowering agents that can be used as second- or third-line agents in the treatment of hypertension. The nondihydropyridines, such as diltiazem or verapamil, have more negative chronotropic effects and are often used to control ventricular rates in atrial fibrillation or other SVTs. Neither class of drug has been shown to decrease overall mortality.

Using digoxin (choice B) as a positive inotropic agent in patients with CHF has no benefit on overall mortality. It has been shown that digoxin does decrease the number of hospital admissions for patients with systolic heart failure.

Nitrates, such as isosorbide dinitrate (choice D), have many therapeutic uses, including the reduction of chest pain in patients with ischemic heart disease as well as being a potent preload reducing agent in acute pulmonary edema. Although nitrates provide symptomatic relief, this class of drugs has never shown a mortality benefit.

Anticoagulation with warfarin (choice E) is often used for prophylaxis against thromboembolism in the setting of atrial fibrillation, a history of pulmonary embolism, or evidence of mural thrombus on echocardiography. The use of warfarin in patients with CHF or ischemic heart disease has never been shown to lower mortality.
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