C. P. is a 46-year-old white man admitted with worsening headache, and nausea and vomiting over 48 hours. The patient is status post single-lung transplant secondary to α1 -antitrypsin deficiency. His immunosuppression regimen includes cyclosporine, prednisone, and azathioprine. As a result of the cyclosporine, he has HTN and renal dysfunction (baseline serum creatinine, 1.9 mg/dL). His BP is controlled with clonidine 0.2 mg twice daily and metoprolol tartrate 25 mg twice daily. Two months ago, he was changed to metoprolol from amlodipine because of peripheral edema. The patient was in his usual state of health until approximately 1 week ago, when he experienced diarrhea, which has since resolved. On admission, his BP was 208/110 mmHg and his serum creatinine was 3.8 mg/dL. What is the most appropriate regimen to control this patient’s BP?
b. Initiate nitroprusside drip and give IV fluids. Hypertensive emergencies are defined by the presence of end-organ damage in the face of high BP. This patient was dehydrated from diarrhea and had uncontrolled BP because of the medication change that occurred. Use of nitroprusside would be most appropriate in this patient because of the emergent situation of the renal insufficiency and possible cerebrovascular involvement exhibited by the headache. Typically, parenteral antihypertensive agents are initiated for hypertensive emergencies. In addition, it is necessary to correct the underlying cause of the hypertensive episode, if it can be identified; therefore, rehydration in this patient is prudent. Nitroprusside is the drug of choice because it has a quick onset of action yet is easily titratable. Sublingual nifedipine is no longer advocated because of the precipitous drop in BP and the subsequent adverse effects.
R. W. is a 60-year-old woman with HF (left ventricular ejection fraction <30%) who has HTN with a BP of 152/90 mmHg. Her potassium is 4.0 mg/dL and serum creatinine is stable at 1.5 mg/dL. She is currently on digoxin and furosemide. Which regimen is most appropriate to initiate in this patient?
d. Lisinopril 5 mg daily. Because the patient is not already receiving ACE inhibitor therapy, an ACE inhibitor is indicated in patients with HF and a reduced ejection fraction (less than 35% to 45%) to decrease morbidity and mortality, as shown in the SOLVD, V-HeFT, and CONSENSUS trials. The patient has no contraindications to such therapy. If the patient’s renal function were changing, thereby making an ACE inhibitor inappropriate, then hydralazine plus a nitrate would be indicated, because V-HeFT I showed mortality benefit compared with placebo and an α-blocker. An angiotensin receptor blocker (ARB), like valsartan, would be indicated if the patient were intolerant to ACE inhibitors in the past. Both ACE inhibitors and ARB should be initiated at low doses, and titrated (as tolerated) to doses proven in clinical trials to reduce cardiovascular events.
A. V. is a 49-year-old woman with a history of HF presenting to the ED for the second time in a month with acutely decompensated HF. She has dyspnea at rest and 3+ edema in her lower extremities. Her serum creatinine is 1.8 mg/dL and BP is 90/60 mmHg. Her home regimen includes enalapril 20 mg twice daily, carvedilol 3.125 mg twice daily, and furosemide 40 mg PO daily. Which of the following is most appropriate for this patient?
a. Admit her to the hospital for IV furosemide therapy and hemodynamic monitoring. Nesiritide is contraindicated for use in patients with systolic BP <90 mmHg. However, based on meta-analyses that raised questions of increased renal dysfunction and mortality associated with nesiritide, the FDA convened a panel to assess available data and provide recommendations regarding appropriate use of nesiritide. These recommendations state that nesiritide should be limited to hospitalized patients with decompensated HF with dyspnea at rest and it should not be used to replace diuretics. Furthermore, because of insufficient evidence, nesiritide should not be used for intermittent outpatient infusions, for scheduled repetitive use, to improve renal function, or to enhance diuresis. A large-scale clinical trial to assess outcomes and further assess the risks of nesiritide versus standard therapy is currently being conducted.
A patient with New York Heart Association class III HF was hospitalized 2 months ago for an exacerbation of his HF. The patient was discharged on lisinopril, furosemide, and digoxin. His lungs are clear and his vital signs are as follows: BP, 105/56 mmHg; heart rate, 84 bpm; and respiration rate, 18. Which regimen is most appropriate to initiate in this patient?
b. Carvedilol 3.125 mg twice daily. All patients with stable, class II or III HF should be initiated on a β-blocker, unless a contraindication (bronchospastic disease, symptomatic bradycardia, or advanced heart block) or intolerance is exhibited. Initiation of β-blocker therapy is recommended in stable patients with mild-to-moderate HF and a low ejection fraction (less than 35% to 40%). The mortality benefit of β-blocker use was seen when added to a preexisting regimen of an ACE inhibitor and diuretic, with or without digoxin. It should be noted that β-blockers must be initiated at very low doses and only gradually increased if low doses have been well tolerated.
Which β-blockers are recommended for use for patients with HF?
b. Carvedilol, metoprolol succinate, bisoprolol. Overwhelming mortality benefit in patients with chronic HF has been proven in clinical trials for carvedilol, metoprolol succinate, and bisoprolol when added to standard HF therapy. These agents are specifically recommended in the ACC/AHA guidelines for the management of chronic heart failure. Despite survival benefit with each of these β-blockers, a class effect with all β-blockers should not be assumed as demonstrated by the Carvedilol or Metoprolol European Trial (COMET). The COMET compared carvedilol with metoprolol tartrate in HF patients and concluded that carvedilol exhibited superior mortality benefit. β-Blockers with ISA should not be used on patients with HF. Pindolol and others with ISA (such as penbutolol, carteolol, and acebutolol) are partial β-agonists and can maintain normal sympathetic tone. This activity prevents the benefits seen with the reduced heart rate, cardiac output, and peripheral blood flow caused by other βblockers.