Aashi
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A 72-year-old white man is seen in the clinic with complaints of increasing dyspnea on exertion and orthopnea. The patient recently moved to the city and has records of a recent hospitalization four months ago for dyspnea upon minimal activity, increasing fatigue, and orthopnea. The patient has a long-standing history of asthma and diabetes. Medications at this time include inhaled steroids, inhaled beta-agonists, and glyburide. ACE inhibitors and furosemide were started two months ago.
Vital signs are: pulse 100/min, respirations 24/min, and blood pressure 154/94 mm Hg. Cardiovascular examination reveals a regular rate and rhythm, and an S4 is present. Bibasilar crackles are evident in the chest. There is no wheezing. There is a trace bilateral pedal edema in the extremities, and routine labs are normal, except for a BUN of 42 mg/dL and a creatinine of 1.9 mg/dL. An EKG shows a sinus rhythm with left ventricular hypertrophy. Chest x-ray shows cardiomegaly and increased vascular congestion. Labs four months ago showed a BUN of 27 mg/dL and a creatinine of 1.2 mg/dL. Echocardiogram shows left ventricular hypertrophy and an ejection fraction of 57%.
What is the next step in management in the management of this patient?
(A) Increase the dose of furosemide
(B) Restrict salt and fluids and reschedule a return appointment in four weeks
(C) Increase the dose of ACE inhibitors
(D) Add digoxin
(E) Start the patient on carvedilol
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| nadiabarati
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E
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| ling
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e
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| dr.wad
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( C ).. INCREASE THE DOSE OF ACE.
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| robin082006
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E is not good choice because this patient as history of asthma.
C is not good choice because Creatinine is increasing.
This patient has hypertension and sign of CHF, he is using furosemide and ACEI but not well controlled--> I go with B first, and A is next option.
Choice B
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| Mahwish Mushtaq
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I'll go with C
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| doc_clotaire
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This patient has sign of APE .......fluid overload .
I would make pee more .
A
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| AAzad
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I go with B if the patient is not in distress and if is stable .
I do not increase the does of any thing since I donot know what does is on right now , I do not give Dig since Ef is good enough, I will be very careful with carvedilol since patient is astmatic is on Oral glycemic agent and if the patient is on Dig.
What do you think
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AAzad
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| Aashi
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Answer:
(E) Start the patient on carvedilol
Explanation:
This patient has congestive heart failure (CHF) due to diastolic dysfunction secondary to chronic hypertension, with no mention of left ventricular (LV) systolic dysfunction. Diastolic dysfunction is more common in elderly, hypertensive patients. Signs of pulmonary or venous congestion in patients with a LV chamber of normal size indicate diastolic dysfunction. The hypertrophic, stiff left ventricle needs more time to fill during diastole, so treatment with beta-blockers helps in slowing the heart rate and increasing cardiac output. Even though he has asthma, his is not wheezing now, and so it would be best to decrease his mortality with beta-blockers. Diuretics and nitrates should be used with caution because the decrease in preload may decrease cardiac output and cause hypotension. The use of increased diuretics is helpful in volume-overloaded patients for relief of severe edema, which is not present in this case. Reassurance, dietary modification alone, and rescheduling a return appointment is not an option in this symptomatic patient. ACE inhibitors are more helpful in patients with LV systolic dysfunction and for lowering the systolic blood pressure. This patient already has prerenal azotemia, and so it would be best to not simply deplete the intravascular volume even further with more diuretics. Positive inotropic agents like digoxin are effective in patients with CHF secondary to systolic dysfunction. Although they do not reduce mortality, these agents are effective in reducing rates of hospitalization and in improving symptoms. They are also useful when worsening heart failure is from atrial fibrillation with poor rate control.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| robin082006
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wow, so tricky, this patient has history of asthma but still uses Carvedilol
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| AAzad
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Thank you for very complete explanation.
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| dr_jojo
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asthma and NON SELECTIVE B blockers .................confused
Edited by dr_jojo on 02/03/07 - 06:17 AM
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| dr_jojo
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The correct answer in this situation which is not provided in this Q to give ca ch blocker
same q in kaplan q bank 2007 ))
and ATENOLOL w is cardio selective (not carvedilol  w is non selective )was one of the choices and the explanation that u canot use b blocker
so
can u Explain that dr aashi ,
it is really confusing
so what is the rule now
Edited by dr_jojo on 02/03/07 - 06:18 AM
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