dilated cariomyopathy...prescribe some medz please! with expln - USMLE Forums
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  #1  
Old 06-14-2012
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Heart dilated cariomyopathy...prescribe some medz please! with expln

A 50-year-old man is brought in by an ambulance to the
emergency department because of increased shortness of
breath for the past two weeks. He feels short of breath on
exertion for the last two years, uses at least two pillows at night,
and denies chest pain or palpitations. He has no history of
ischemic heart disease. He is not compliant with his medications
and forgets to take his "water pills." He has five vodka martinis
every night. The patient has been smoking one pack of
cigarettes a day for the past 30 years. Last month he was treated
in another hospital for alcohol withdrawal symptoms.
On physical examination, the patient is lying in bed and is
slightly short of breath. His temperature is 97.0 F, heart rate is
78/min, respiratory rate is 22/min, and blood pressure is 150/80
mm Hg. The neck veins are distended. There is cardiomegaly
and an S3 gallop. On lung auscultation, there are crackles at
both bases. The liver edge is palpated 2 cm below the right
costal margin. There is 1+ bilateral leg edema.
EKG shows low QRS voltage, nonspecific ST-segment and T
changes. The chest x-ray shows cardiomegaly and mild
pulmonary congestion. Left ventricular dilation is found by
echocardiogram.
What is your choice of therapy at this time?
(A) Captopril, furosemide, beta-blockers
(B) Losartan, furosemide, coumadin
(C) Captopril, spironolactone, digoxin
(D) Captopril, furosemide, digoxin, coumadin
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  #2  
Old 06-14-2012
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C........?????
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symptoms are controlled with Diuretics and digoxin

ace/arb/bb/spironolactone can be added for long term management.

either A or C
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Quote:
Originally Posted by K06100 View Post
C........?????
expln ?
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Quote:
Originally Posted by tyagee View Post
expln ?

I simply followed the ADD criteria of the RALES trial ie.Ace inhibitors,Diuretics, Digoxin.......and came up with choice C......I don't know anything more specific
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Old 06-14-2012
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C...

ACE inhibitors help slow the left ventricular remodelling

Digoxin is a postive inotropic agent to increase cardiac contractility and control the Sx of dyspnea.

Spirinolactone is given to stage 3 and 4 CHF with SOB on rest or minimal exertion. In this question it doesn't sound like he has that exactly. It's effect will be inhibiting aldosterone.

I think if his pulmonary congestion was not "mild" and worse, then I would have chosen a choice with a loop diuretic.

What is the answer?
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Old 06-14-2012
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I agree with C.

Diuretics, more diuretics (particularly spironolactone because it is an aldosterone antagonist so helps with fluid overload) and digoxin.
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Old 06-15-2012
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also, digoxin messes up potassium(dont remember how exactly, probably displaces K from the Na/K pump), & a potassium sparing diuretic will not cause hypokalemia, thus preventing or decreasing side effects of digoxin
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Old 06-15-2012
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-PT ON acute so bb;CI
-LOSARTAN use if the captopril isNOT TOLERATE;not B
-SPIRONALACTON in hf not used as diuratic(diuratic is acornerstone here);not C
-SO it D:PT ISNOTcompliant with his rx ;coumadin can reduce mortality from thromboses.
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Old 06-15-2012
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Default ans is B !

Initial treatment usually consists of diuretics, ACE
inhibitors, and beta-blockers.

The addition of digoxin depends of presence
of decreased left ventricular function and the persistence of symptoms despite the use of ACE inhibitors, diuretics, and beta-blockers.

Chronic
anticoagulation must be considered but should only be used if there were
evidence of thrombosis.

Angiotensin-receptor blockers are
indicated when patients cannot tolerate ACE inhibitors because of adverse
effects, such as a cough.

is this correct?
any patient not having decomponsated CHF should be on BB ? i remember from my med school days teacher told me that once patient is shifted from ICU to ward, BB are started. i may be wrong....
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Quote:
Originally Posted by tyagee View Post
Initial treatment usually consists of diuretics, ACE
inhibitors, and beta-blockers.

The addition of digoxin depends of presence
of decreased left ventricular function and the persistence of symptoms despite the use of ACE inhibitors, diuretics, and beta-blockers.

Chronic
anticoagulation must be considered but should only be used if there were
evidence of thrombosis.

Angiotensin-receptor blockers are
indicated when patients cannot tolerate ACE inhibitors because of adverse
effects, such as a cough.

is this correct?
any patient not having decomponsated CHF should be on BB ? i remember from my med school days teacher told me that once patient is shifted from ICU to ward, BB are started. i may be wrong....
i distinctly remember conrad fischer saying that beta blockers are never started in an acute setting.


also ACE I and ARBs are used for CHRONIC MANAGEMENT... not in the acute setting.


the only drugs one can use in the acute setting are (pretty much the same ones for acute pulmonary edema)
1- diuretics
2-dobutamine
3- hydralazine/nitrates.

all others are for chronic Rx.

i donot get this question at all!
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Old 06-15-2012
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Sorry answer is a
Sorry
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Old 06-16-2012
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Quote:
Originally Posted by tyagee View Post
Sorry answer is a
Sorry
MTB 2 pg 79..the last sentence in the answer paragraph states "Do not give beta blockers in the acute treatment of CHF. "
Your guy in the question is an acute case in the ED. So I am not sure about (A) being the answer here.
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Old 06-16-2012
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And although I chose C as the answer before..I am thinking that doesn't make sense either because Digoxin takes weeks to start working. I am still confused about the set up of choices in this question because they don't take into regard the acute setting of the pt.
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Old 06-17-2012
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Default qbank expln

This patient presents with dilated cardiomyopathy and displays signs of
biventricular heart failure. Chronic alcohol abuse is one of the most
frequent causes of dilated cardiomyopathy. The management is similar to
that of congestive heart failure related to ischemia. The offending agent
should be discontinued. Initial treatment usually consists of diuretics, ACE
inhibitors, and beta-blockers. The addition of digoxin depends of presence
of decreased left ventricular function and the persistence of symptoms
despite the use of ACE inhibitors, diuretics, and beta-blockers. Chronic
anticoagulation must be considered but should only be used if there were
evidence of thrombosis. In addition, coumadin should be used with
extreme caution in an alcoholic. Angiotensin-receptor blockers are
indicated when patients cannot tolerate ACE inhibitors because of adverse
effects, such as a cough.
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Old 06-17-2012
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i too think patient is in pulmonary edema not just chf.
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Old 06-17-2012
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Why is it not CHF?
He has at least FIVE major criteria for CHF.

Framingham criteria
By the Framingham criteria, diagnosis of congestive heart failure (heart failure with impaired pumping capability)[6] requires the simultaneous presence of at least 2 of the following major criteria or 1 major criterion in conjunction with 2 of the following minor criteria:

Major criteria:

Cardiomegaly on chest radiography
S3 gallop (a third heart sound)
Acute pulmonary edema
Paroxysmal nocturnal dyspnea
Crackles on lung auscultation
Central venous pressure of more than 16 cm H2O at the right atrium
Jugular vein distension
Positive abdominojugular test
Weight loss of more than 4.5 kg in 5 days in response to treatment (sometimes classified as a minor criterium[31])

Minor criteria:
Tachycardia of more than 120 beats per minute
Nocturnal cough
Dyspnea on ordinary exertion
Pleural effusion
Decrease in vital capacity by one third from maximum recorded
Hepatomegaly
Bilateral ankle edema
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