A 56-year-old man presents to your clinic for follow-up after being discharged from the hospital 6 weeks ago. He underwent a successful primary angioplasty for acute anterior MI; however, his EF is now 40%. He is currently taking simvastatin (Zocor), acetylsalicylic aspirin, clopidogrel bisulfate (Plavix), metoprolol tartrate (Lopressor), and losartan (Cozaar). He states that he cannot afford all of these medications. He would like to know which medications are essential for a longer life.
Which medications should you tell him are essential?
All of them except losartan. There is no trial evidence that angiotensin II receptor blocker improved mortality in post-MI patients. The Studies of Left Ventricular Dysfunction (SOLVD) prevention used ACE inhibitors in patients with an EF less than 35%.
A 78-year-old woman with congestive heart failure (CHF) (EF, 25%), chronic atrial fibrillation (AFib), gastroesophageal reflux disease, HTN, hyperlipidemia, diabetes, and osteoporosis takes 12 different pills. At the recent senior citizen day at the local church, a nurse told her that she does not need to take digoxin because she is on amiodarone. She wants to eliminate digoxin from her medication regimen, and she wants to know why you put her on it in the first place.
What is your answer?
Digoxin reduces hospitalization. In the large Digitalis Investigation Group study, digitalis only improved hospitalization. It had no effect on survival.
Recently, a 43-year-old lawyer received heart transplantation. His hospital course was unremarkable, and he was discharged. He found out from the heart failure nurses that allograft vasculopathy is the leading cause of longterm morbidity and mortality in transplant patients. He wants to know what proven treatments prevent allograft vasculopathy.
Which of the following treatments should you recommend?
No known treatment. Allograft vasculopathy is the leading cause of longterm morbidity and mortality for cardiac transplant patients. Routine cardiac catheterization has been advocated for these patients but has not shown survival benefit with revascularization. Statin therapy appears to improve long-term survival in these patients and should be used for all heart transplant patients. However, its effect on allograft vasculopathy is unknown.
A 72-year-old woman is transferred from another hospital. She was initially admitted with palpitation, diagnosed with AFib, and treated with amiodarone. A transthoracic echocardiogram (TTE) showed an EF of 10% with a regional wall motion abnormality. She underwent cardiac catheterization and was found to have a heavily calcified 80% lesion in the mid–left anterior descending artery (LAD), a 40% lesion in a nondominant circumflex, and an 80% lesion in the posterior descending artery. Her children want to know what you plan to do for her.
What should you recommend?
She should have a positron emission tomography (PET) scan to assess the area of viability before proceeding with CABG or PCI. This patient is at high risk for any type of intervention because of her low EF. However, if there are areas of viability on the PET scan, her EF might improve with complete revascularization. Studies have consistently shown that patients with low EF do better with CABG than with PCI.
A 53-year-old woman with a history of CHF presents to the emergency room (ER). She is cool and clammy. She reports being short of breath. Her blood pressure (BP) is 71/40 mmHg, her heart rate (HR) is 110 bpm, and her respiratory rate is 30. She has elevated neck veins and a prominent S3 . Her echocardiogram (ECG) shows sinus tachycardia. She is admitted to the CCU (coronary care unit) with heart failure. A pulmonary artery (PA) catheterization is performed, and her hemodynamics are as follows: right atrial (RA) pressure, 12 mmHg; PA pressure, 62/30 mmHg; cardiac output, 1.9 L/min/m2 ; pulmonary capillary wedge pressure (PCWP), 36 mmHg; and systemic vascular resistance (SVR), 2,000 dyne/s/cm5 .
Which of the following is your next step?
Start dopamine. This patient is in cardiogenic shock. She needs BP support before all else. In these patients, dopamine is the first line of choice, followed by norepinephrine. If there is no change with dopamine and norepinephrine, then dobutamine may be added while the patient is being prepared for IABP placement.
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