docnikki
Forum Guru
Topics: 93
Posts: 680
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A 78-year-old man with a history of coronary artery disease, congestive heart failure (CHF), and hyperlipidemia was admitted to CCU three days ago with a diagnosis of non-Q-wave myocardial infarction (MI). He was transferred to a regular floor yesterday after he was stabilized.
His current medications include aspirin, metoprolol 25 orally twice a day, nitroglycerin, furosemide 40 mg orally twice a day, and simvastatin. Physical examination shows a pulse of 82/min, a respiratory rate of 16/min, and a blood pressure of 112/62 mm Hg. There are minimal bibasilar crackles on lung examination, an S4 gallop on cardiac examination, and a trace edema in the extremities. Echocardiogram shows decreased left ventricular systolic function. You start him on captopril 6.25 mg every eight hours and double the dose with each additional dose until you reach the minimal effective dose of 50 mg three times a day. The following day, the nurse informs you that his blood pressure dropped to 95/49 mm Hg, with a pulse of 94/min, and she is hesitant to give any antihypertensive medications. What would be the most appropriate response?
(A) Discontinue metoprolol
(B) Discontinue captopril
(C) Reduce the dose of furosemide
(D) No intervention because his blood pressure drop is transient
([font size="2"]E) Hold all medications[/font]
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| Korotkoff
Forum Senior
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Posts: 164
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I will say reduce the furosemide. I am not sure.
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| farnsworth
Forum Newbie
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reducing the furosemid (C) is a good choice. The combination of ACEI and loop diuretics typically creates a drop in blood pressure. The effect is indeed transient, and there is evidence that beta-receptor antagonists and ACEI are beneficial after myocardial infarction.
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| docnikki
Forum Guru
Topics: 93
Posts: 680
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very nice
ACE inhibitors such as captopril have become standard therapy for CHF because they have been shown to decrease mortality. They should be started with small doses and titrated up as tolerated because of a possible hypotensive effect. The final dosage should be 50 mg orally every 8 hours. This is the minimum needed to achieve the needed effect on relieving afterload. Remember, however, that there is virtually no reason to use a cumbersome three-times-a-day medication such as captopril for an outpatient when drugs such as ramipril, quinapril, lisinopril, and fosinopril can be used once a day and with far greater adherence.
This patient developed his hypotensive episode a full day after being on a higher dose of the ACE inhibitor. The hypotensive episode may therefore not be directly related to just the use of the ACE inhibitor. The diuretic dose may need downward adjustment or be withheld for 24 hours. Besides having only minimal signs of fluid overload, the question is making sure you know that it is more important to first remove drugs that don't have a definite effect on lowering mortality. In addition, reducing the dose of Lasix to 20 or 40 mg once a day will not result in any harm to the patient
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