docnikki
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A 60-year-old woman comes to your office with complaints of progressive fatigue. She is unable to make it through the day without tiring and hasn't been sleeping well due to waking up in the middle of the night short of breath. She is also concerned about a 10-pound weight gain over the past month. She has a past medical history of hypertension, hypercholesterolemia, and diabetes mellitus. Her medications include metformin, atenolol, hydrochlorothiazide, and atorvastatin. The doses haven't changed over the past two years. Vital signs are: blood pressure 167/96 mm Hg, heart rate 78/min, and respiratory rate 20/min. There is some mild jugular venous distension at 30 degrees, bibasilar rales, a holosystolic murmur at the apex radiating to the axilla, and a mild pitting edema of the ankles. Which of the following would be appropriate at this time?
(A) Echocardiogram to determine direction of action
(B) Digoxin
(C) Increase the dose of atenolol
(D) Start ACE inhibitors
(E) Stop the atenolol
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| farnsworth
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Very good question: D
rationale: the patient most likely suffers from mitral valve insufficiency. To decrease the reflux across the incompetent mitral valve the systemic vascular resistance/left ventricular afterload should be decreased. Furthermore the RAAS is already activated (weight gain, increased CVP, bibasilar crackles), so ACEI should be used to 'break' this chain.
An echo should be done anyway to determine the extent of the mitral insufficiency.
Digoxin is an option in the treatment of mitral valve insufficiency, especially when AFib has evolved. But this is not the first line intervention.
In the end, the patient needs surgery, since afterload reduction does not delay or eliminate the need for surgery.
Atenolol: if the patient has congestive heart failure, it may be beneficial to keep him on beta-receptor antagonists (atenolol has a half live of 6-7 hrs, if you stop it, the effect would be gone by 4 half lifes -> 24hrs. So stopping atenolol may improve the situation as early as after 1 day)
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| Korotkoff
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Agree with D.
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| doc_clotaire
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I would like to have the diagnosis documented first before giving him ACE inh and also check the EF
A
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| farnsworth
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doc_clotaire: echo is a good choice. The "direction of action" is already clear: decrease the afterload.
Echo helps to determine the extent of the mitral valve insufficiency (causative therapy is valve replacement). The EF is difficult to determine, as a significant part of the ejected volume goes in 'backward direction' (to the atrium). Furthermore the left ventricle does not seem to be severely compromised, as it can build up a blood pressure of >160/90mmHg! So I think, it is pretty safe to give ACEI w/o prior echo (although I would like to have the MIV documented, as well a left ventricular contractility).
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| RX 135
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c chf with htn..if ni work start ace
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| docnikki
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hmmm its a tricky one!
Farnsworth..ur explainations are very impressive as always..but there is a slight twist in here. It is CHF..but it could be a diastolic dysfunction ( because of the high BP) or a systolic dysfunction ( coz of the MR) so we need to determine what it is as treatment may vary..here's the explaination!
At this point, there is not enough information to determine if this is systolic or diastolic cardiac dysfunction. Longstanding hypertension can lead to either type of cardiomyopathy. If an S3 gallop was heard or an echocardiogram confirmed a low ejection fraction, then choice D, ACE inhibitors, would be correct. If an S4 was heard or an echocardiogram definitely showed diastolic dysfunction, then choice C, increasing the beta-blockers, would be the correct choice for treating diastolic dysfunction. Choice B, adding digoxin, would not be appropriate at this time. Digoxin is only helpful to decrease symptoms in systolic dysfunction. If the patient still has symptoms of dyspnea after starting an ACE inhibitor, then adding digoxin to relieve symptoms would be appropriate. Beta-blockers are appropriate for both systolic and diastolic dysfunction, so choice E, stopping the atenolol, is not appropriate. The best data for evidence for a decrease in mortality are for carvedilol and metoprolol, although it is probably an effect of the entire class of medications. Switching the diuretic to a loop diuretic, such as furosemide, and starting a salt-restricted diet are generally appropriate for all forms of congestive failure.
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| sherry39
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what the answer
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| dr.wad
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very nice q docnikki.......it opens a new widows in mx of heart failure.
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