Prognosis in heart failure correlates best with which of the following?
V˙E /V˙O2 slope during exercise. This is the best correlate of prognosis. There is a higher ventilation for any given CO2 production (V˙E /V˙O2 slope), which reflects the severity of heart failure and prognosis.
An 86-year-old woman is transferred from a nursing home in respiratory distress. She was found to be short of breath. On examination, she has labored breathing, and her BP is 62/34 mmHg with an HR of 60 bpm. She is intubated in the ER and admitted to the CCU. She is started on norepinephrine and dopamine at high doses without significant effect. Her ECG shows sinus bradycardia but is otherwise unremarkable. Her chest Xray (CXR) shows pulmonary edema. The nursing home calls and says that she has mistakenly received 100 mg IV metoprolol tartrate.
Which of the following should be your next step?
Glucagon and milrinone. Milrinone is a second-generation phosphodiesterase inhibitor. It has no β-effect; therefore, it is an ideal vasopressor in the setting of β-blocker overdose. Although a pacer is a good idea and should be placed, giving medication is faster and should be instituted first.
A 62-year-old man with an EF of 20% and chronic renal insufficiency presents to your office for follow-up. He has non-insulin-dependent diabetes mellitus and has developed worsening renal failure caused by diabetes. His medication regimen includes a β-blocker that is significantly affected by reduced renal function.
Which of the following β-blockers is he taking?
Atenolol. Atenolol is most affected by reduced renal function. Depending on how severe his creatinine clearance is, he should have his medication dose or frequency adjusted.
A 38-year-old patient with CHF is transferred from another hospital. You are doing rounds in the CCU while the clinicians are performing a TTE. They ask you to assess his LV function. You notice that the E:A wave ratio is greater than 1.5, with an E-wave deceleration time of 120 milliseconds.
Which of the following do you guess is his PCWP?
PCWP is 26 mmHg. Restrictive mitral inflow pattern in the presence of a short E-wave deceleration time has been shown to correlate with high pulmonary capillary pressure, impaired functional class, and bad prognosis in postinfarction patients.
For this patient, the E:A wave ratio and the E-wave deceleration time indicate which of the following?
High filling pressure and reduced LV compliance. These conditions are indicated by a restrictive mitral inflow pattern with short E-wave deceleration time.
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