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| * cardio Q, NOT NBME! .................Try this |
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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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| * Re:cardio Q, NOT NBME! .................Try this |
| #2188406 |
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diastolic heart failure,diabetic with high bp..so beta blocker..carvedilol is cardio selective,probably could use in asthmatics.
B..would be right but schedule him after 4 weeks ,i think not fair when he is suffering from severe dyspnea. |
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| * Re:cardio Q, NOT NBME! .................Try this |
| #2188562 |
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Joined: 06 Nov 2008
Posts: 2534
85332 Credits
Posted: Thu Mar 19, 2009 2:11 pm Post subject:
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E
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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| * Re:cardio Q, NOT NBME! .................Try this |
| #2188585 |
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#2154616
heist - 07/24/10 15:42
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Nitrates and hydralazine improve mortality in black patients with CHF - the trial is called A-Heft trial. But it's not your first choice. BB should be on the list of meds, but it's less effective in black people. ACE should be started first. If the patient doesn't have controlled HTN and you've added hydralazine ==> it's worth it to add nitrate as the next agent in order to have that combination.
As for mannitol, it's an osmotic diuretic. It can redistribute (to reach equilibrium) from the intravascular compartment into the extracellular compartment and cause fluid shift ==> if you used it in pulm edema, you'd be causing more fluids into the pulm interstitial tissue ==> worsened edema. Thus it's contraindicated here. But you can used in cases of increased intracranial pressure (ICP). I guess (not very sure though) due to the BBB, it remains in the intravascular compartment ==> pulls fluids into the vessels ==> decrease the cerebral edema and the ICP. That's why it's helpful in the cerebral edema, but detrimental in the pulm edema.
Another theory about mannitol is that when you inject it acutely into the veins, it's very hypertonic and pulls fluids into the vessels from all tissues ==> increased fluids in intravascular compartment, and thus hydrostatic pressure. Well, you know that the pulm edema didn't come out of the blue. Mostly because of a cardiac problem (like CHF). So if you give a med that increases the intravascular volume ==> CHF would worsen ==> pulm edema would worsen.
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* Re:cardiopul q reposted
#2154768
cardiofellow - 07/24/10 21:24
E. BETA BLOCKER- carvedilol
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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| * Re:cardio Q, NOT NBME! .................Try this |
| #2188589 |
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#2154873
heist - 07/25/10 01:05
I didn't find any articles about absolute contraindication for BB in asthmatic patients. She's on inhaled steroids and short acting beta-agonists, which means her asthma is only mild (mild intermittent to mild persistent at the most). She's not in an acute exacerbation right now. And carvedilol is B2 selective. Starting a low dose wouldn't kill the patient. Not to mention carvedilol is one of the BB that improve mortality. So it's worth trying.
Btw, some debate is going on right now about the usefulness of using BB in chronic asthma :)
So, yeah, carvedilol is a good one. But if it were up to me, I'd try a CCB. Once kidney function improve, I'll go up on the ACE. HTN needs to be controlled in this lady.
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