A 49-year-old man is admitted with new-onset heart failure. He is diagnosed with dilated cardiomyopathy with an EF of 20%. On hospital day 1, he is diuresed and started on a regimen of furosemide, digoxin, acetylsalicylic aspirin, captopril, and simvastatin. A medical student wants to know why you did not start him on a β-blocker.
The same medical student wants to know whether the patient should also be started on calcium channel blockers.
What is your answer?
Amlodipine proved to be of small benefit in a NYHA class III or IV patient with an EF <30%. This benefit was seen more in dilated cardiomyopathy patients. In the Prospective Randomized Amlodipine Survival Evaluation Trial, in which NYHA class III or IV patients with an EF less than 30% were enrolled, there was a statistically insignificant reduction in the combined mortality and morbidity in the amlodipine group. However, the benefit appeared to be greater in patients with nonischemic cardiomyopathy.
A 24-year-old female medical student presents to urgent care with 5 days of fever and shortness of breath. She is diagnosed with a viral infection and sent home. Five months later during her physical examination class, she is found to have an S3 by her fellow students. She presents to your office for a second opinion. On examination, she appears healthy and in no distress. Her BP is 96/50 mmHg, with an HR of 71 bpm and a respiratory rate of 12. Her neck veins are not distended, and her examination is unremarkable except for an enlarged heart. You do not appreciate an S3 . You order a TTE, which shows an EF of 20% with a dilated heart. There is no valvular abnormality.
Which of the following is your recommendation?
Begin ACE inhibitor and β-blockers. She has well-compensated cardiomyopathy. Only medication that prolongs her life needs to be started. She does not need medication for symptom relief; therefore, ACE inhibitor and β-blockers should be started.
A 79-year-old man with diabetes, HTN, chronic renal insufficiency, and ischemic cardiomyopathy was recently admitted with CHF exacerbation. At home, he takes captopril, 75 mg t.i.d.; digoxin, 0.125 mg per day; furosemide, 60 mg b.i.d.; aspirin; and atorvastatin calcium (Lipitor). When admitted, he was in heart failure with elevated neck veins and S3 . During his admission, he was diuresed with IV furosemide and metolazone. His baseline creatinine was 1.7 and now is 2.5, with blood urea nitrogen of 100.
What is your next step?
Stop diuretics. This patient has prerenal azotemia caused by aggressive diuresis. His renal function should recover.
The severity of symptomatic exercise limitation in heart failure
Bears little relation to the severity of LV dysfunction. Short-term administration of positive inotropic agents and vasodilators does not improve maximal exercise capacity in patients with CHF. Moreover, ACE inhibitors have failed to show consistent improvement in exercise tolerance. Numerous studies have not shown a correlation between LV function and exercise tolerance.
A 59-year-old woman with CHF and an EF of 30% comes to your office for follow-up. She is on carvedilol (Coreg), enalapril, aspirin, atorvastatin calcium, digoxin, and furosemide. She has been doing well without any rehospitalization. However, she wants to improve her exercise tolerance.
What should you recommend?
Enrolling her in an exercise training program. As stated, there is no medication that has consistently shown improvement in exercise tolerance; exercise training is the only method that has shown consistent improvement in these patients.
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