Cardiology>>>>>Pharmacology
Question 52#

Which of the following statements is true?

A. Serum levels are used to guide the selection of the dose of digoxin
B. Because spironolactone was found to have mortality benefit in the Randomized Aldactone Evaluation Study (RALES), the addition of spironolactone should be considered for all HF patients
C. The benefit of long-term IV inotropic therapy may outweigh the increased mortality risk in refractory patients unable to be weaned from IV inotropic support
D. Digoxin exhibits both symptomatic and mortality benefit in patients with HF

Correct Answer is C

Comment:

c. The benefit of long-term IV inotropic therapy may outweigh the increased mortality risk in refractory patients unable to be weaned from IV inotropic support. Because long-term IV positive inotropic therapy may cause an increased risk of death, such therapy is not regularly recommended. This risk, however, may be outweighed in patients who cannot be weaned from continuous support. Such patients with refractory HF may experience an improved quality of life because of the relative clinical stability afforded by the inotrope; therefore, IV positive inotropic therapy may be considered as a palliative measure in end-stage HF. The DIG (Digitalis Investigation Group) trial showed that digoxin’s benefit in HF was the alleviation of symptoms and improvement in clinical status. These findings were associated with a decreased morbidity (fewer hospitalizations) but not mortality. Because digoxin has negligible effect on survival, it is recommended that digoxin be used in conjunction with diuretics, ACE inhibitors, and β-blockers to decrease the clinical symptoms of HF. Furthermore, little evidence supports the practice of dosing digoxin according to serum levels. This is because of the lack of data exhibiting a relationship between digoxin serum concentrations and therapeutic effect. In the RALES trial, spironolactone was shown to be associated with reduced mortality and morbidity. However, the patients who were included in this trial were patients with class IV HF. Therefore, it would only be prudent to consider spironolactone in patients with recent or current severe HF symptoms. Efficacy and safety of spironolactone’s use in patients with mild-to-moderate HF is yet to be determined.