Aashi
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A 60-year-old man presents with recurrent episodes of dyspnea on minimal exertion. He has a prior medical history significant for hypertrophic cardiomyopathy for 15 years, and for the past year his symptoms have become more severe and bothersome. He frequently complains of chest pain, orthopnea, nocturnal dyspnea, chronic nonproductive cough, weight gain, and peripheral edema. His medications include atenolol 50 mg BID, verapamil, disopyramide, and Lasix. Physical examination reveals an anxious tachypneic male who is afebrile with a blood pressure of 110/70 mm Hg without pulsus paradoxus. The respiratory rate is 30/min. Jugular veins are distended, and the heart sounds are distant. There are third and fourth heart sounds present, as well as bilateral rhonchi. The liver is enlarged, and pedal edema is present. The EKG shows nonspecific ST-T changes in the lateral leads. Chest x-ray reveals cardiomegaly with pulmonary congestion. The echocardiogram displays ventricular dilatation and mitral regurgitation with an ejection fraction of 35%. Three sets of cardiac enzymes are negative. What is the best medical management at this time?
(A) Add captopril to present regimen
(B) Increase the dose of Lasix and continue present regimen
(C) Stop the verapamil and disopyramide and start captopril
(D) Increase the dose of beta-blocker, verapamil, and Lasix; stop the disopyramide and start captopril
(E) Continue with present management
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| robin082006
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This patient has CHF so verapamil and Disopyramide should be discontinued.
Change Atenolol to carvedilol with care.
Add Captopril.
Choice C
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| CocaCola
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agreed with above 
c
verampimil and disopyramide could worsten heart failure
afterload needs to be reduced so add ACE inh
But robin i dont understand why change atenolol to carvedilol?
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| dr.wad
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( D )
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| Aashi
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Answer:
(C) Stop the verapamil and disopyramide and start captopril
Explanation:
In 5% of patients, hypertrophic cardiomyopathy may "burn out" into a condition more typical of dilated cardiomyopathy. This is characterized by the development of thinner myocardial walls, diminishment of the outflow gradient, and the development of mitral regurgitation. These patients tend to have symptoms of congestive heart failure (CHF) at left ventricular ejection fractions that are not severely reduced, often in the range of 30 to 40%, as opposed to the usual case of dilated cardiomyopathy in which severe symptoms are rare above an ejection fraction of 25%. When this occurs, such patients should discontinue verapamil and disopyramide, which work to decrease inotropic state, and continue beta-blockers only at low doses and with caution. Patients should begin therapy with ACE inhibitors and diuretics as needed for fluid retention, as one would in any other patient with dilated cardiomyopathy.
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| webjeee
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robin082006 wrote:
This patient has CHF so verapamil and Disopyramide should be discontinued.
Change Atenolol to carvedilol with care.
Add Captopril.
Choice C
Robin, would you please tell me why change atenolol to carvedilol?
Thank you. I am really not good at cardio.
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| robin082006
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For CHF mixed beta blocker (alpha and beta) is preferred than selective B 1 blockers because of increased sympathetic activities in CHF.
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| dr_jojo
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but Aashi i thought that we should avoid DILATORS and digoxin in hypertrophic cardiomyopathy is this true only in earlier stages before burn out to dilated
as i know the 1st line for hypertrophic is BBlockers
2nd is ca ch blockers
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