A 55-year-old man presents with gradually increasing shortness of breath and leg swelling that occurred while on a business trip. He has congestive heart failure, which has caused fatigue and shortness of breath if he walks a block or climbs a flight of stairs. Blood pressure is 140/90; there is no jugular venous distension or gallop, and only minimal pedal edema. An echocardiogram shows left ventricular ejection fraction is 45%. Current medications include aspirin and simvastatin. The patient desires to keep medications to a minimum. What additional treatments are indicated at this time?
There is very good evidence that ACE inhibitors should be used in patients with symptomatic and asymptomatic congestive heart failure (a depressed left ventricular ejection fraction < 40%). ACE inhibitors stabilize left ventricular remodeling, improve symptoms, reduce hospitalization, and decrease mortality. Beta-blocker therapy represents a major advance in the treatment of patients with congestive heart failure. These drugs interfere with the harmful effects of sustained activation of the adrenergic nervous system (α1 , β1 , and β2 ) by competitively blocking their receptors. When given with ACE inhibitors, beta-blockers stabilize left ventricular remodeling, improve patient symptoms, reduce hospitalization, and decrease mortality. An aldosterone antagonist is recommended for patients with NYHA class III or IV symptoms who have a left ventricular ejection fraction of less than 35% and who are still symptomatic despite receiving standard therapy with diuretics, ACE inhibitors, and beta-blockers. Likewise, digoxin may improve symptoms of patients with advanced symptomatic congestive heart failure. Neither of these drugs is indicated in this patient with mild symptoms. Furosemide is used to improve symptoms but does not prolong survival. Since this patient wants to minimize medications, an ACE inhibitor and beta-blocker are better first choices because they confer a survival advantage. An implantable defibrillator is indicated in systolic heart failure with left ventricular ejection fraction less than 30% to 35% in order to prevent sudden cardiac death, but is not indicated in this patient whose ejection fraction is 45%.
A 34-year-old woman is referred by an OB-GYN colleague for the onset of fatigue and dyspnea on exertion 1 month after her second vaginal delivery. Physical examination reveals a laterally displaced PMI, elevated jugular venous pressure, and pitting lower extremity edema. Echocardio-gram shows systolic dysfunction with an ejection fraction of 30%. Which statement most accurately describes her condition?
Although peripartum (or postpartum) cardiomyopathy may occur during the last trimester of pregnancy or within 6 months of delivery, it most commonly develops in the month before or after delivery. The most common demographics are multiparity, African American race, and age greater than 30. About half of patients will recover completely, with most of the rest improving, although the mortality rate is 10% to 20%. These women should avoid future pregnancies due to the risk of recurrence. Treatment is as for other dilated cardiomyopathies, except that ACE inhibitors are contraindicated in pregnancy. Diagnosis can typically be made without invasive testing.
Yesterday you admitted a 55-year-old man to the hospital for an episode of chest pain. The patient has past medical history of COPD, peripheral vascular disease with claudication, hypertension and hypercholesterolemia. On admission his BMI is 40, there is bilateral wheezing, and cardiac examination reveals a grade 1/6 early systolic murmur at the upper left sternal border without radiation. Blood pressure readings have consistently been 140/90 to 150/100. Cardiac enzymes are normal. A resting ECG shows left ventricular hypertrophy with secondary ST-T-wave changes (“LVH with strain”). You decide to do a cardiac stress test on this patient. Which cardiac stress test would be most appropriate for this patient?
The choice of initial stress test modality depends on the patient’s resting ECG, ability to exercise, and the availability of expertise and technology. Exercise electrocardiographic test should be the initial stress test in patients with an interpretable ECG who are able to exercise. When certain resting ECG abnormalities are present (ST depression > 1 mm, left ventricular hypertrophy, bundle branch block, paced rhythm, or pre-excitation), either nuclear imaging or echocardiography is the preferred initial stress imaging. Pharmacologic stimulation of heart rate should be used in patients who are unable to exercise. For patients with concomitant valve disease, pericardial disease, or aortic disease, echocardiography has the advantage of providing information regarding these issues. The major limitation of echocardiography is in patients in whom satisfactory imaging may be technically difficult to acquire satisfactory images. This is often the case is patients with COPD or morbid obesity. In this patient a standard exercise ECG stress test is not appropriate because of the baseline ECG abnormalities. An exercise nuclear test would probably be impossible because of his claudication. Thus he should have a pharmacologic test. In the setting of COPD, adenosine is best avoided because it can aggravate bronchospasm. Because both obesity and COPD compromise echocardio-graphic detail, a stress echo is not the best choice.
A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His blood pressure is 110/80 and lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings?
The classic triad of symptoms in aortic stenosis includes exertional dyspnea, angina pectoris, and syncope. Physical findings include a narrow pulse pressure and systolic murmur. The remaining answers describe aortic insufficiency murmur, mitral regurgitation murmur, mitral valve prolapse click, and a rub associated with pericarditis. These conditions are not associated with syncope as a presenting symptom.
A 72-year-old man presents with shortness of breath that awakens him at night. He is unable to walk more than one city-block before stopping to catch his breath. Physical examination findings include normal blood pressure, bilateral basilar rales, and neck vein distention. The patient has diabetes and a known history of congestive heart failure. His last echocardiogram revealed a left ventricular ejection fraction of 25%. The patient has compliant with his medication regimen that includes an ACE inhibitor, beta-blocker, a loop diuretic, metformin, and glipizide. What is the most likely etiology for the patient’s heart failure?
Coronary artery disease has become the predominant primary cause of congestive heart failure in industrialized countries, causing 60% to 75% of cases. Coronary artery disease, hypertension, and diabetes mellitus interact to augment the risk of heart failure in many patients, but coronary artery disease is the primary cause in most. In 20% to 30% of patients the exact etiology is not known. These patients are referred to as having nonischemic, dilated, or idiopathic cardiomyopathy. Prior viral infection or toxins (eg, alcohol or chemotherapy) may also lead to a dilated cardiomyopathy. Specific genetic defects such as mutations of genes encoding cytoskeletal proteins (desmin, cardiac myosin, vinculin), and nuclear membrane proteins (lamin) have been identified that may cause dilated cardiomyopathy. The condition is also associated with Duchenne, Becker, and limb girdle muscular dystrophies. Conditions that lead to a high cardiac output (eg, arteriovenous fistula, anemia) are seldom solely responsible for the development of heart failure.
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