darkhorse
Forum Elite
Topics: 56
Posts: 275
|
A 60-year-old man is hospitalized after he is taken to the emergency department because of dyspnea and leg edema. He has a longstanding history of essential hypertension that is treated with a thiazide diuretic and amlodipine. Coronary angiography performed 1 year ago because of chest pain was normal, but left ventriculogram showed an ejection fraction of 45%. On admission, blood pressure is 180/100 mm Hg and heart rate is 110/min and regular. Jugular venous distension is 10 cm while the patient is lying on a stretcher with his head elevated at 45 degrees. He has a positive hepatojugular reflex, 2+ pitting leg edema to the knees, soft S1 and S2, an S3 gallop, and diffuse pulmonary crackles. No heart murmurs are auscultated. Echocardiogram shows left ventricular ejection fraction of 20% and left ventricular end-diastolic dimension in diastole of 7 cm. He has 1+ mitral and 1+ tricuspid regurgitation with an estimated right ventricular systolic pressure of 40 mm Hg. Electrocardiogram shows a left bundle branch block. Serum electrolytes and hepatic and renal function measurements are normal. Acute ischemic syndrome is excluded by repeated measurements of cardiac enzymes. He receives furosemide, three boluses of 60 mg intravenously, and nesiritide over a 24-hour period and improves rapidly with diuresis of 2200 mL. Which of the following drugs should be initiated before discharge to improve long-term survival in this patient?
A. Digoxin
B. Furosemide
C. Carvedilol
D. Lisinopril
E. Spironolactone
___________________
When going gets tough, the tough gets going
|
| cool doctor
Forum Junior
Topics: 1
Posts: 226
|
C?
|
| doyoudig
Forum Guru
Topics: 144
Posts: 613
|
D. Lisinopril
|
| drduck
Forum Guru
Topics: 82
Posts: 529
|
patient is going into congestive cardiac failure....
no other drug reduces the mortality in such patients except ACE inhibitors...
they prevent ventricular remodelling and prevents rupture.
beta blockers and angiotensin receptor blockers are also seen to reduce the mortality but not like ACE inhibitors.
|
| doyoudig
Forum Guru
Topics: 144
Posts: 613
|
the impt point here is that the Pt has Systolic Dysf w/ a Low EF hence ACE is the prefferd Drug
whereas Pt w/ Diastolic Probl would recieve BB initially
at least tha't my reason for preffering ace over carvedilol. BB can than be added as an adjunct if ACE and Loops fail .....
|
| chemamr
Moderator and PGY2
Topics: 703
Posts: 4,442
|
I guess D is the answer here.  ?
___________________
Any time something is written against me, I not only share the sentiment but feel I could do the job far better myself.
|
| Vietnamese
Forum Elite
Topics: 12
Posts: 285
|
C is my option. Carvedilol is evident in multi-center randomised studys and improve survival life significantly, especially lower EF is improverd more rapid under Carvedilol.
___________________
Nothing is impossible.
|
| darkhorse
Forum Elite
Topics: 56
Posts: 275
|
The correct answer is D
Educational Objectives
Recognize the best strategy for drug implementation at discharge in a patient who is hospitalized because of decompensated congestive heart failure.
Critique
Although this patient requires therapy with multiple drugs, treatment with an ACE inhibitor should be initiated. ACE inhibitors are root agents to which β-blockers are added to reduce the rates of mortality and morbidity in patients who have congestive heart failure and systolic left ventricular dysfunction. β-blockers are usually started on an outpatient basis once the dose of ACE inhibitor is optimized and the patient is considered euvolemic. More recently, efforts have been mounted to validate the safety of also starting β-blockers in the hospital. This patient requires diuretics to achieve and maintain euvolemia but diuretics do not improve survival. Long-term treatment with a cardiac glycoside, such as digoxin, has no apparent effect on mortality in this situation. However, when coupled with ACE inhibitors, these agents reduce the incidence of deterioration and hospitalization associated with heart failure. Aldosterone antagonists should be reserved for older patients who have persistent New York Heart Association class 3/4 symptoms and are receiving an aggressive baseline protocol, including digoxin, a diuretic, an ACE inhibitor, and a β-blocker. Because calcium channel blockers have no proven benefit in reducing morbidity and mortality rates in patients with systolic left ventricular dysfunction, amlodipine is not a first-line drug in this patient. Amlodipine can be an adjunctive antihypertensive agent if blood pressure is not controlled after the patient is given the target doses of an ACE inhibitor and a β-blocker in combination with a diuretic.
___________________
When going gets tough, the tough gets going
|
| chemamr
Moderator and PGY2
Topics: 703
Posts: 4,442
|
D 
___________________
Any time something is written against me, I not only share the sentiment but feel I could do the job far better myself.
|
| deja_vu
Forum Senior
Topics: 4
Posts: 214
|
Excellant work darkhorse.Thanks man for this wonderful explanation.
|
| alzheimer
Forum Newbie
Topics: 4
Posts: 41
|
Thanks Chevalnoir or darkhorse
wonderful question
|
|
| |
| | | | | | | | | | | |
