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ABFM HEART DISEASE
A 66 65-year- old 66 female 66 who 66 has 66 heart 66 failure 66 with 66 an 66 ejection 66 fraction 66 of 66 35% 66 is 66 found 66 to 66 have 66 a 66 TSH 66 level 66 of 66 13.8 66 μU/mL 66 (N 66 0.3- 4.82). 66 Her 66 T3 66 and 66 T4 66 levels 66 are 66 normal, 66 and 66 her 66 thyroid 66 gland 66 is 66 normal 66 t o 66 palpation. 66 You 66 check 66 her 66 levels 66 again 66 in 66266 months 66 and 66 they 66 are 66 unchang ed. 66 You 66 advise 66 her 66 that hypothyroidism 66 decreases 66 her 66 metabolic 66 rate, 66 which 66 reduces 66 the 66 stress 66 on 66 he r 66 heart hypothyroidism 66 is 66 detrimental 66 to 66 her 66 heart 66 only 66 if 66 she 66 develops 66 hypothyroid 66 s ymptoms subclinical 66 hypothyroidism 66 has 66 negative 66 effects 66 on 66 heart 66 failure 66 and 66 treatment 6 6 should 66 be 66 considered treatment 66 of 66 subclinical 66 hypothyroidism 66 would 66 raise 66 her 66 LDL-cholesterol 66 level 66 - 66 answer--C Clinical 66 hypothyroidism 66 has 66 long 66 been 66 associated 66 with 66 cardiac 66 dysfunction. 66 It 66 has 66 also 66 been 66 shown 66 that 66 subclinical 66 hypothyroidism 66 (TSH 66 >4 66 μU/ mL 66 with 66 normal 66 or 66 borderline 66 low 66 thyroid 66 hormone 66 levels) 66 can 66 cause 66 left 66 ve ntricular 66 systolic 66 and 66 diastolic 66 dysfunction, 66 which 66 improves 66 with 66 thyroid 66 replace ment 66 therapy. 66 Patients 66 with 66 overt 66 or 66 subclinical 66 hypothyroidism 66 should 66 be 66 trea ted 66 with 66 levothyroxine 66 to 66 improve 66 their 66 cardiovascular 66 function 66 and 66 decrease 66 t he 66 potential 66 risk 66 of 66 heart 66 failure. 66 Thyroxine 66 in 66 excess 66 can 66 exacerbate 66 coronar y 66 artery 66 disease, 66 and 66 should 66 be 66 started 66 at 66 low 66 doses 66 and 66 increased 66 slowly 66 in 66 patients 66 with 66 possible 66 underlying 66 coronary 66 artery 66 disease. 66 Results 66 of 66 meta- analyses 66 indicate 66 that 66 therapy 66 will 66 lower, 66 not 66 raise, 66 serum 66 LDL- cholesterol 66 levels. A 66 58-year- old 66 male 66 is 66 hospitalized 66 with 66 severe 66 decompensated 66 heart 66 failure 66 refractory 66 to 66 intravenous 66 inotropic 66 therapy 66 and 66 guideline- directed 66 medical 66 therapy. 66 You 66 are 66 considering 66 referral 66 to 66 a 66 tertiary 66 care 66 hosp ital 66 for 66 mechanical 66 circulatory 66 support 66 to 66 bridge 66 to 66 transplantation.Which 66 one 66 of 66 the 66 following 66 is 66 true 66 regarding 66 mechanical 66 circulatory 66 support 66 bridge 66 therap y? It 66 should 66 be 66 limited 66 to 66 patients 66 who 66 meet 66 the 66 criteria 66 for 66 heart 66 transplantatio n
It 66 should 66 only 66 be 66 used 66 in 66 patients 66 with 66 biventricular 66 heart 66 failure It 66 generally 66 improves 66 quality 66 of 66 life 66 while 66 waiting 66 for 66 transplantation It 66 greatly 66 reduces 66 quality 66 of 66 life 66 while 66 waiting 66 for 66 transplantation 66 - 66 answer--c Mechanical 66 circulatory 66 support 66 (MCS) 66 with 66 a 66 ventricular 66 assist 66 device 66 has 66 con tinued 66 to 66 evolve 66 and 66 has 66 emerged 66 as 66 a 66 viable 66 therapeutic 66 option 66 for 66 patient s 66 with 66 advanced 66 stage 66 D 66 heart 66 failure 66 with 66 reduced 66 ejection 66 fraction 66 refractor y 66 to 66 guideline- directed 66 medical 66 therapy 66 and 66 cardiac 66 device 66 intervention. 66 A 66 variety 66 of 66 ventricu lar 66 assist 66 devices 66 are 66 now 66 available. 66 These 66 devices 66 may 66 be 66 either 66 intracorpo real 66 or 66 extracorporeal, 66 and 66 may 66 be 66 designed 66 to 66 assist 66 the 66 left 66 ventricle, 66 right 66 ventricle, 66 or 66 both.Bridge 66 therapy 66 refers 66 to 66 the 66 use 66 of 66 left 66 ventricular 66 assist 66 devices 66 to 66 help 66 a 66 patient 66 survive 66 until 66 a 66 donor 66 heart 66 becomes 66 available 66 for 66 transplantation. 66 Several 66 devices 66 are 66 available, 66 some 66 of 66 which 66 are 66 implantable 6 6 and 66 allow 66 patients 66 to 66 be 66 discharged 66 to 66 their 66 homes. 66 These 66 devices 66 can 66 inc rease 66 patient 66 activity 66 levels 66 and 66 quality 66 of 66 life. 66 Complications 66 can 66 occur, 66 inclu ding 66 stroke, 66 infection, 66 and 66 death, 66 but 66 these 66 devices 66 can 66 be 66 lifesaving 66 in 66 pati ents 66 with 66 refractory 66 heart 66 failure.The 66 data 66 from 66 the 66 Interagency 66 Registry 66 for 66 Mechanically 66 Assisted 66 Circulatory 66 Support 66 indicates 66 that 66 cardiogenic 66 shock, 66 ad vanced 66 age, 66 and 66 severe 66 right 66 heart 66 failure 66 (manifested 66 as 66 ascites 66 or 66 increas ed 66 bilirubin) 66 are 66 major 66 risk 66 factors 66 for 66 death 66 after 66 MCS. 66 This 66 led 66 to 66 a 66 reco mmendation 66 that 66 referral 66 for 66 MCS 66 be 66 considered 66 before 66 severe 66 right 66 ventricul ar 66 failure 66 develops. 66 Possible 66 indications 66 for 66 a 66 bridge-to- candidacy 66 ventricular 66 assist 66 device 66 include 66 obesity, 66 tobacco 66 use, 66 and 66 severe 66 pulmonary 66 hypertension 66 in 66 patients 66 who 66 might 66 otherwise 66 be 66 candidates 66 for 66 tra nsplantation. An 66 active 66 66-year- old 66 female 66 presents 66 with 66 intermittent 66 chest 66 pain 66 and 66 dyspnea. 66 She 66 is 66 currentl y 66 pain 66 free. 66 A 66 resting 66 EKG 66 is 66 normal.If 66 found 66 on 66 the 66 history 66 and 66 examinatio n, 66 which 66 one 66 of 66 the 66 following 66 symptoms 66 is 66 most 66 likely 66 to 66 be 66 associated 66 with 66 myocardial 66 ischemia 66 as 66 the 66 cause 66 of 66 chest 66 pain? An 66 episode 66 of 66 diaphoresis 66 associated 66 with 66 the 66 chest 66 pain Pain 66 reproduced 66 by 66 chest 66 wall 66 palpation 66 on 66 the 66 left 66 side 66 of 66 the 66 chest Pain 66 that 66 comes 66 and 66 goes 66 with 66 and 66 without 66 exertion Intermittent 66 pleuritic-type 66 pain 66 and 66 dyspnea 66 - 66 answer--A Cardiac 66 ischemia 66 is 66 classically 66 defined 66 as 66 deep, 66 poorly 66 localized 66 chest 66 or 66 ar m 66 discomfort 66 reproducibly 66 associated 66 with 66 exertion 66 or 66 emotional 66 stress. 66 It 66 is 66 r elieved 66 with 66 rest 66 and 66 nitroglycerin. 66 It 66 can 66 present 66 in 66 an 66 atypical 66 fashion, 66 and 66 the 66 discomfort 66 can 66 localize 66 or 66 radiate 66 to 66 the 66 neck, 66 lower 66 jaw, 66 throat, 66 shoul der, 66 epigastrium, 66 hands, 66 or 66 upper 66 back. 66 It 66 may 66 be 66 entirely 66 absent 66 in 66 some 66 cases. 66 In 66 older 66 patients 66 without 66 chest 66 pain, 66 new- onset 66 or 66 unexplained 66 exertional 66 dyspnea 66 is 66 the 66 most 66 common 66 anginal 66 equival ent, 66 even 66 with 66 a 66 normal 66 resting 66 EKG.Although 66 they 66 may 66 be 66 present, 66 pleuritic
blocker 66 in 66 selected 66 patients 66 with 66 moderately 66 severe 66 to 66 severe 66 symptoms 66 of 66 h eart 66 failure 66 and 66 a 66 reduced 66 LVEF.Although 66 the 66 addition 66 of 66 digoxin 66 can 66 be 66 of 6 6 benefit 66 in 66 selected 66 heart 66 failure 66 patients 66 by 66 reducing 66 the 66 risk 66 for 66 hospitalizati on, 66 it 66 has 66 not 66 been 66 shown 66 to 66 reduce 66 mortality 66 (SOR 66 B). 66 According 66 to 66 recen t 66 guidelines, 66 patients 66 are 66 considered 66 candidates 66 for 66 cardiac 66 resynchronization 66 t herapy 66 if 66 they 66 have 66 NYHA 66 class 66 II- IV 66 heart 66 failure, 66 a 66 left 66 ventricular 66 ejection 66 fraction 66 ≤35%, 66 and 66 a 66 QRS 66 duratio n 66 >130 66 ms 66 on 66 an 66 EKG. 66 However, 66 30%- 35% 66 of 66 patients 66 who 66 meet 66 these 66 criteria 66 are 66 nonresponders 66 with 66 no 66 sympto matic 66 improvement 66 or 66 reverse 66 left 66 ventricular 66 remodeling. 66 Left 66 bundle 66 branch 66 block 66 morphology, 66 a 66 QRS 66 duration 66 ≥150 66 ms, 66 and 66 adequate 66 coronary 66 sinus 66 a natomy 66 have 66 been 66 most 66 closely 66 associated 66 with 66 a 66 favorable 66 response. 66 Mitral 6 6 valve 66 regurgitation, 66 right 66 ventricular 66 dysfunction, 66 and 66 atrial 66 fibrillation 66 have 66 be en 66 shown 66 to 66 have 66 a 66 negative 66 impact 66 on 66 patient 66 r You 66 admit 66 a 66 patient 66 with 66 acute 66 coronary 66 syndrome 66 to 66 the 66 hospital. 66 Which 66 o ne 66 of 66 the 66 following 66 is 66 true 66 regarding 66 the 66 differences 66 between 66 low 66 molecular 66 weight 66 heparin 66 (LMWH) 66 and 66 unfractionated 66 heparin 66 (UFH) 66 in 66 this 66 situation? The 66 use 66 of 66 glycoprotein 66 IIb/ IIIa 66 inhibitors 66 does 66 not 66 require 66 a 66 change 66 in 66 the 66 dosage 66 of 66 UFH The 66 dosage 66 of 66 both 66 should 66 be 66 titrated 66 to 66 achieve 66 a 66 partial 66 thromboplastin 66 ti me 66 of 66 1.5-2.5 66 times 66 control Platelet 66 activation 66 is 66 the 66 same 66 for 66 both The 66 incidence 66 of 66 thrombocytopenia 66 is 66 lower 66 with 66 LMWH UFH 66 has 66 higher 66 bioavailability 66 because 66 it 66 is 66 given 66 intravenously 66 - 66 answer--D Anticoagulation 66 is 66 recommended 66 in 66 addition 66 to 66 antiplatelet 66 therapy 66 for 66 all 66 patie nts 66 with 66 acute 66 coronary 66 syndrome 66 regardless 66 of 66 the 66 initial 66 treatment 66 strategy. 6 6 For 66 patients 66 managed 66 with 66 an 66 early 66 invasive 66 strategy, 66 heparin 66 exerts 66 its 66 anti coagulant 66 effect 66 by 66 accelerating 66 the 66 action 66 of 66 circulating 66 antithrombin. 66 It 66 is 66 av ailable 66 as 66 either 66 intravenous 66 unfractionated 66 heparin 66 (UFH) 66 or 66 subcutaneous 66 lo w 66 molecular 66 weight 66 heparin 66 (LMWH).LMWH 66 offers 66 greater 66 bioavailability 66 than 66 UFH 66 because 66 of 66 decreased 66 binding 66 to 66 plasma 66 proteins 66 and 66 endothelial 66 cells, 6 6 and 66 it 66 results 66 in 66 less 66 platelet 66 activation. 66 The 66 incidence 66 of 66 thrombocytopenia 66 i n 66 patients 66 treated 66 with 66 LMWH 66 is 66 less 66 than 66 with 66 UFH. 66 LMWH 66 does 66 not 66 chan ge 66 the 66 partial 66 thromboplastin 66 time 66 (PTT) 66 appreciably, 66 so 66 PTT 66 should 66 not 66 be 66 used 66 to 66 monitor 66 the 66 dosage. 66 LMWH 66 is 66 a 66 viable 66 option 66 for 66 treatment 66 of 66 acut e 66 coronary 66 artery 66 syndrome 66 and 66 is 66 preferred 66 in 66 many 66 situations.If 66 UFH 66 is 66 us ed 66 it 66 should 66 be 66 given 66 intravenously 66 at 66 a 66 dosage 66 of 668566 U/ kg 66 unless 66 a 66 glycoprotein 66 IIb/ IIIa 66 inhibitor 66 is 66 also 66 administered, 66 in 66 which 66 case 66 the 66 dosage 66 should 66 be 66 redu ced 66 to 666066 U/ kg. 66 Dosing 66 adjustments 66 should 66 be 66 based 66 on 66 the 66 target 66 activated 66 clotting 66 time
. 66 Patients 66 treated 66 with 66 UFH 66 should 66 be 66 monitored 66 by 66 factor 66 Xa 66 assays.
An 66 82-year- old 66 female 66 presents 66 with 66 increasing 66 dyspnea. 66 Her 66 husband 66 is 66 worried 66 becaus e 66 she 66 occasionally 66 stops 66 breathing 66 when 66 she 66 is 66 asleep. 66 You 66 have 66 been 66 trea ting 66 the 66 patient 66 for 66 heart 66 failure 66 for 66 the 66 past 66266 years 66 with 66 ACE 66 inhibitors, 66 β -blockers, 66 diuretics, 66 and 66 low- dose 66 spironolactone 66 (Aldactone). 66 The 66 nurse 66 who 66 measures 66 the 66 patient's 66 blood 66 pressure 66 notes 66 that 66 the 66 systolic 66 sounds 66 are 66 heard 66 first 66 at 66 a 66 pressure 66 of 661 3566 mm 66 Hg 66 and 66 a 66 pulse 66 rate 66 of 664066 beats/ min. 66 At 6612066 mm 66 Hg 66 the 66 nurse 66 hears 66 Korotkoff 66 sounds 66 at 66 a 66 regular 66 rate 66 of 6 6 80/min.Which 66 one 66 of 66 the 66 following 66 is 66 true 66 regarding 66 this 66 patient? The 66 examination 66 findings 66 are 66 normal 66 for 66 patients 66 in 66 this 66 age 66 group The 66 patient's 66 breathing 66 pattern 66 is 66 normal 66 for 66 patients 66 in 66 this 66 age 66 group Both 66 the 66 breathing 66 and 66 blood 66 pressure 66 findings 66 may 66 improve 66 with 66 more 66 inten sive 66 treatment Medications 66 should 66 be 66 reduced 66 in 66 this 66 patient 66 because 66 her 66 blood 66 pressure 66 is 66 unstable 66 - 66 answer--C This 66 patient 66 has 66 pulsus 66 alternans, 66 which 66 is 66 common 66 in 66 patients 66 with 66 decomp ensated 66 heart 66 failure 66 and 66 advanced 66 myocardial 66 disease. 66 Effective 66 treatment 66 ca n 66 make 66 this 66 finding 66 disappear. 66 Cheyne- Stokes 66 breathing 66 is 66 also 66 common 66 in 66 patients 66 with 66 decompensated 66 heart 66 failur e. 66 If 66 the 66 heart 66 failure 66 is 66 treated, 66 the 66 breathing 66 abnormality 66 can 66 disappear. 66 Th e 66 patient 66 has 66 symptomatic 66 heart 66 failure, 66 which 66 classifies 66 her 66 heart 66 failure 66 as 6 6 stage 66 C 66 at 66 least, 66 according 66 to 66 the 66 American 66 College 66 of 66 Cardiology/ American 66 Heart 66 Association 66 heart 66 failure 66 guidelines. A 66 69-year-old 66 female 66 presents 66 to 66 the 66 emergency 66 department 66 with 66 a 66 1- hour 66 episode 66 of 66 severe 66 substernal 66 chest 66 pain 66 that 66 has 66 now 66 resolved. 66 Her 66 p ast 66 medical 66 history 66 is 66 notable 66 for 66 current 66 tobacco 66 abuse, 66 hypertension, 66 and 66 d epression. 66 Her 66 current 66 medications 66 include 66 lisinopril/ hydrochlorothiazide 66 (Zestoretic), 66 10/12.5 66 mg 66 daily; 66 citalopram 66 (Celexa), 662066 mg 66 daily; 66 and 66 aspirin, 668166 mg 66 daily. 66 On 66 examination 66 she 66 has 66 a 66 blood 66 pressure 66 of 66 150/92 66 mm 66 Hg 66 and 66 a 66 pulse 66 rate 66 of 669266 beats/ min. 66 An 66 EKG 66 reveals 66 a 66 sinus 66 rhythm 66 with 66 deep 66 and 66 symmetrical 66 T- wave 66 inversions 66 in 66 the 66 inferior 66 leads.You 66 decide 66 to 66 admit 66 the 66 patient 66 to 66 the 6 6 hospital. 66 Which 66 one 66 of 66 the 66 following 66 should 66 be 66 administered 66 on 66 admission? Alteplase 66 (Activase) 66 intravenously Aspirin, 668166 mg, 66 and 66 nitroglycerin 66 via 66 intravenous 66 drip Enoxaparin 66 (Lovenox), 66166 mg/ kg 66 subcutaneously, 66 and 66 nitroglycerin, 66 0.4 66 mg 66 sublingually Ticagrelor 66 (Brilinta), 666066 mg 66 orally, 66 and 66 enoxaparin, 66166 mg/kg 66 subcutaneou 66 - 66 answer--E
A 66 2/6 66 diastolic 66 murmur 66 and 66 weak 66 radial 66 and 66 femoral 66 pulses Diffuse 66 ST-segment 66 elevation 66 of 66 1-2 66 mm A 66 pulsus 66 paradoxus 66 of 661066 mm 66 Hg Chest 66 and 66 back 66 pain 66 that 66 was 66 mild 66 initially 66 and 66 increased 66 over 66 the 66 next 66266 hours 66 - 66 answer--B The 66 chest 66 pain 66 of 66 aortic 66 dissection 66 is 66 typically 66 described 66 as 66 searing, 66 ripping, 6 6 or 66 tearing, 66 and 66 frequently 66 radiates 66 to 66 the 66 back 66 or 66 lower 66 extremities. 66 The 66 pai n 66 is 66 worst 66 at 66 the 66 time 66 of 66 onset 66 and 66 lasts 66 for 66 hours. 66 Helpful 66 findings 66 on 66 ph ysical 66 examination 66 include 66 asymmetry 66 of 66 pulses 66 or 66 blood 66 pressure, 66 as 66 well 66 a s 66 a 66 new 66 murmur 66 of 66 aortic 66 regurgitation 66 (a 66 decrescendo 66 early 66 diastolic 66 murmu r 66 heard 66 best 66 in 66 the 66 aortic 66 area, 66 as 66 opposed 66 to 66 holosystolic 66 murmurs). 66 This 66 t ype 66 of 66 murmur 66 indicates 66 a 66 dissection 66 involving 66 the 66 ascending 66 aorta. 66 The 66 diss ection 66 can 66 extend 66 to 66 the 66 pericardial 66 sac 66 and 66 produce 66 a 66 pericardial 66 friction 66 ru b 66 on 66 examination, 66 as 66 well 66 as 66 findings 66 of 66 cardiac 66 tamponade. 66 Pulsus 66 paradox us 66 is 66 a 66 common 66 finding 66 of 66 cardiac 66 tamponade 66 and 66 is 66 defined 66 by 66 a 66 decreas e 66 in 66 blood 66 pressure 66 of 66 at 66 least 661266 mm 66 Hg 66 with 66 inspiration.Aortic 66 dissection 66 i s 66 not 66 usually 66 associated 66 with 66 acute 66 ischemic 66 electrocardiographic 66 changes. 66 Da ta 66 from 66 the 66 International 66 Registry 66 of 66 Aortic 66 Dissection 66 indicates 66 that 66 ischemic 6 6 changes 66 were 66 present 66 on 66 an 66 EKG 66 in 66 only 66 15% 66 of 66 cases. 66 The 66 diagnosis 66 ca n 66 be 66 established 66 with 66 transesophageal 66 echocardiography, 66 CT, 66 or 66 MRI. 66 The 66 im portance 66 of 66 early 66 diagnosis 66 in 66 a 66 patient 66 being 66 evaluated 66 for 66 myocardial 66 infarc tion 66 is 66 underscored 66 by 66 the 66 fact 66 that 66 aortic 66 dissection 66 is 66 exacerbated 66 by 66 fibrin olytic 66 therapy 66 and 66 anticoagulation.Acute 66 aortic 66 dissection 66 has 66 a 66 lethality 66 rate 66 of 66 1%- 2% 66 per 66 hour 66 after 66 the 66 onset 66 of 66 symptoms 66 in 66 untreated 66 patients. 66 Prompt 66 diag nosis 66 is 66 therefore 66 vital 66 to 66 increase 66 the 66 patient's 66 chances 66 of 66 survival 66 and 66 pre vent 66 serious 66 complications. 66 Advanced 66 age, 66 male 66 sex, 66 a 66 long- term 66 history 66 of 66 arterial 66 hypertension, 66 and 66 the 66 presence 66 of 66 an 66 aortic 66 aneurysm 66 confer 66 the 66 greatest 66 population- attributable 66 risk. 66 However, 66 patients 66 with 66 genetic 66 connective 66 tissue 66 disorders 66 su ch 66 as 66 Marfan, 66 Loeys-Dietz, 66 or 66 Ehlers-Danlos 66 syndrome, 66 and 66 patients 66 wit A 66 62-year- old 66 male 66 comes 66 to 66 your 66 office 66 for 66 a 66 routine 66 health 66 maintenance 66 evaluation. 66 He 66 has 66 a 66 history 66 of 66 hypertension, 66 type 66266 diabetes, 66 and 66 New 66 York 66 Heart 66 As sociation 66 class 66 II 66 heart 66 failure. 66 His 66 current 66 medications 66 include 66 metformin 66 (Glu cophage), 6650066 mg 66 twice 66 daily; 66 benazepril 66 (Lotensin), 664066 mg 66 daily; 66 chlorthalido ne, 66 12.5 66 mg 66 daily; 66 atorvastatin 66 (Lipitor), 661066 mg 66 daily; 66 and 66 aspirin, 668166 mg 66 da ily. 66 A 66 physical 66 examination 66 is 66 notable 66 only 66 for 66 a 66 BMI 66 of 662966 kg/ m2 66 and 66 a 66 blood 66 pressure 66 of 66 135/80 66 mm 66 Hg. 66 His 66 hemoglobin 66 A1c 66 is 66 6.9%. Which 66 one 66 of 66 the 66 following 66 additional 66 medications 66 would 66 be 66 appropriate 66 to 66 h elp 66 manage 66 his 66 heart 66 failure? Amlodipine 66 (Norvasc) Digoxin
Losartan 66 (Cozaar) Metoprolol 66 succinate 66 (Toprol-XL) Metoprolol 66 tartrate 66 (Lopressor) 66 - 66 answer--D Current 66 American 66 Heart 66 Association 66 guidelines 66 recommend 66 that 66 a 66 β- blocker, 66 specifically 66 either 66 carvedilol, 66 bisoprolol, 66 or 66 metoprolol 66 succinate, 66 be 66 pr escribed 66 to 66 all 66 patients 66 with 66 stable 66 heart 66 failure 66 with 66 a 66 reduced 66 left 66 ventricul ar 66 ejection 66 fraction. 66 These 66 three 66 β- blockers 66 have 66 all 66 been 66 shown 66 to 66 prolong 66 survival 66 in 66 patients 66 with 66 current 66 or 6 6 prior 66 symptoms 66 of 66 heart 66 failure. 66 A 66 class 66 effect 66 cannot 66 be 66 assumed. 66 Studies 6 6 have 66 shown 66 short- acting 66 metoprolol 66 tartrate 66 to 66 be 66 less 66 effective 66 than 66 sustained- release 66 metoprolol 66 succinate 66 in 66 reducing 66 the 66 risk 66 of 66 death 66 in 66 patients 66 with 66 c hronic 66 heart 66 failure. 66 Losartan 66 should 66 not 66 be 66 added 66 to 66 an 66 ACE 66 inhibitor. 66 Aml odipine 66 adds 66 no 66 benefit 66 for 66 heart 66 failure. 66 Digoxin 66 would 66 not 66 be 66 indicated 66 in 66 this 66 patient 66 since 66 there 66 is 66 no 66 history 66 of 66 atrial 66 fibrillation 66 or 66 other 66 tachyarrhyth mia. You 66 see 66 a 66 63-year-old 66 female 66 for 66 follow- up 66266 months 66 after 66 coronary 66 artery 66 bypass 66 graft 66 (CABG) 66 surgery. 66 In 66 addition 66 to 66 clopidogrel 66 or 66 a 66 similar 66 antiplatelet 66 medication, 66 which 66 one 66 of 66 the 66 following 6 6 should 66 you 66 recommend 66 to 66 reduce 66 the 66 repeat 66 revascularization 66 rate 66 following 66 CABG 66 surgery? Aspirin 66 and 66 β-blockers Aspirin 66 and 66 statin 66 therapy β-Blockers 66 and 66 statin 66 therapy Postmenopausal 66 hormone 66 therapy 66 and 66 statin 66 therapy 66 - 66 answer--B Aspirin 66 has 66 been 66 shown 66 to 66 significantly 66 reduce 66 vein 66 graft 66 closures 66 through 66 th e 66 first 66 postoperative 66 year. 66 According 66 to 66 current 66 guidelines 66 it 66 should 66 be 66 contin ued 66 indefinitely, 66 given 66 its 66 benefit 66 in 66 preventing 66 subsequent 66 clinical 66 events. 66 Aft er 66 off- pump 66 coronary 66 artery 66 bypass 66 graft 66 (CABG) 66 surgery, 66 dual 66 antiplatelet 66 therapy 66 should 66 be 66 administered 66 for 66166 year 66 using 66 a 66 combination 66 of 66 aspirin, 66 81- 16266 mg 66 daily, 66 and 66 clopidogrel, 667566 mg 66 daily, 66 to 66 reduce 66 graft 66 occlusion. 66 Aggre ssive 66 statin 66 therapy 66 following 66 CABG 66 has 66 been 66 shown 66 to 66 result 66 in 66 less 66 disea se 66 progression 66 in 66 saphenous 66 vein 66 grafts 66 and 66 to 66 reduce 66 the 66 repeat 66 revascular ization 66 rate. 66 The 66 American 66 Heart 66 Association 66 recommends 66 high- intensity 66 statin 66 therapy 66 (atorvastatin, 66 40-80 66 mg 66 daily, 66 or 66 rosuvastatin, 66 20- 4066 mg 66 daily) 66 after 66 surgery 66 for 66 all 66 CABG 66 patients 66 <75 66 years 66 of 66 age 66 and 66 mo derate-intensity 66 statin 66 therapy 66 for 66 patients 66 intolerant 66 of 66 high- intensity 66 statin 66 therapy 66 and 66 those 66 >75 66 years 66 of 66 age. 66 Hormone 66 therapy 66 and 66 β- blockers 66 have 66 not 66 been 66 shown 66 to 66 affect 66 the 66 revascularization 66 rate. 66 Postmeno
ncrease 66 the 66 response 66 of 66 platelets 66 to 66 arachidonic 66 acid, 66 thus 66 increasing 66 thromb oxane 66 A2 66 production 66 and 66 platelet 66 aggregation, 66 and 66 to 66 lead 66 to 66 accelerated 66 at herosclerosis 66 in 66 chronic 66 users. 66 Increased 66 motor 66 activity, 66 along 66 with 66 skeletal 66 m uscle 66 injury 66 and 66 rhabdomyolysis, 66 is 66 also 66 associated 66 with 66 cocaine 66 use, 66 causing 66 creatine 66 kinase 66 and 66 even 66 CK- MB 66 elevation 66 in 66 the 66 absence 66 of 66 myocardial 66 infarction. 66 As 66 a 66 result, 66 cardiac 66 tr oponin 66 I 66 or 66 T 66 is 66 preferred 66 for 66 detecting 66 myocardial 66 necrosis.In 66 most 66 cases 66 th e 66 initial 66 management 66 of 66 cocaine- associated 66 chest 66 pain 66 should 66 include 66 nitrate 66 therapy 66 and 66 a 66 benzodiazepine. 66 B enzodiazepines 66 relieve 66 cocaine- associated 66 chest 66 pain 66 and 66 also 66 reduce 66 anxiety 66 and 66 the 66 central 66 stimulatory 66 eff ects 66 of 66 the 66 cocaine, 66 indirectly 66 improving 66 hypertension 66 and 66 tachycardia. 66 Nitrate 6 6 therapy 66 has 66 been 66 shown 66 to 66 reduce 66 cocaine- associated 66 chest 66 pain, 66 reverse 66 cocaine- associated 66 vasoconstriction, 66 and 66 lower 66 blood 66 pressure. 66 Nifedipine 66 is 66 not 66 recom mended 66 as 66 first- line 66 treatment 66 but 66 other 66 calcium 66 channel 66 blockers 66 such 66 as 66 diltiazem 66 may 66 be 6 6 used 66 for 66 blood 66 pressure 66 control. 66 It 66 was 66 previously 66 thought 66 that 66 β- blockers 66 were 66 harmful 66 in 66 patients 66 with 66 chest 66 pain 66 associated 66 with 66 cocaine 66 in gestion 66 but 66 that 66 has 66 been 66 disproven 66 in 66 many 66 recent 66 studies. 66 Labetalol 66 and 66 metoprolol 66 are 66 both 66 safe 66 and 66 may 66 have 66 a 66 beneficial 66 effect 66 in 66 this 66 situation.T his 66 patient's 66 EKG 66 is 66 characteristic 66 of 66 Wellens 66 syndrome, 66 or 66 left 66 anterior 66 desc ending 66 coronary 66 artery 66 (LAD) 66 T-wave 66 syndrome. 66 These 66 EKG 66 changes A 66 61-year-old 66 male 66 sees 66 you 66 for 66 a 66 follow- up 66 visit. 66 His 66 medical 66 history 66 includes 66 end- stage 66 heart 66 failure, 66 chronic 66 atrial 66 fibrillation, 66 a 66 left 66 ventricular 66 ejection 66 fraction 6 6 of 66 30%, 66 and 66 stage 66466 chronic 66 kidney 66 disease. 66 He 66 is 66 taking 66 optimal 66 dosages 6 6 of 66 lisinopril 66 (Prinivil, 66 Zestril), 66 metoprolol 66 succinate 66 (Toprol- XL), 66 furosemide 66 (Lasix), 66 digoxin, 66 and 66 spironolactone 66 (Aldactone). 66 He 66 continues 6 6 to 66 have 66 symptoms 66 of 66 heart 66 failure 66 with 66 minimal 66 exertion, 66 but 66 not 66 at 66 rest. 66 A n 66 EKG 66 shows 66 a 66 ventricular 66 rate 66 of 668566 beats/ min, 66 a 66 QRS 66 duration 66 of 66 0.14 66 sec, 66 and 66 old 66 Q 66 waves 66 in 66 the 66 inferior 66 leads.Ap propriate 66 management 66 options 66 for 66 this 66 patient 66 include 66 which 66 one 66 of 66 the 66 follo wing? Adding 66 a 66 nondihydropyridine 66 calcium 66 channel 66 blocker Adding 66 a 66 thiazide 66 diuretic Switching 66 from 66 metoprolol 66 succinate 66 to 66 metoprolol 66 tartrate 66 (Lopressor) Synchronized 66 biventricular 66 pacing 66 - 66 answer--D Biventricular 66 pacing 66 with 66 an 66 implantable 66 defibrillator 66 can 66 improve 66 symptoms 66 an d 66 increase 66 survival 66 in 66 heart 66 failure 66 patients 66 with 66 a 66 prolonged 66 QRS 66 duration, 66 and 66 is 66 recommended 66 for 66 those 66 with 66 a 66 low 66 ejection 66 fraction, 66 given 66 their 66 incre ased 66 risk 66 for 66 ventricular 66 fibrillation.Patients 66 with 66 refractory 66 heart 66 failure 66 on 66 opti mal 66 medical 66 therapy 66 should 66 be 66 considered 66 for 66 a 66 heart 66 transplant. 66 Patients 66 wi
th 66 an 66 anticipated 66 1- year 66 survival 66 probability 66 <50% 66 can 66 benefit 66 from 66 left 66 ventricular 66 (LV) 66 assist 66 de vices. 66 Patients 66 who 66 have 66 a 66 narrow 66 QRS 66 and 66 stage 66 D 66 heart 66 failure 66 despite 66 optimal 66 medical 66 therapy, 66 and 66 who 66 are 66 not 66 candidates 66 for 66 transplant 66 or 66 LV 66 a ssist 66 devices, 66 should 66 not 66 receive 66 a 66 defibrillator 66 if 66 their 66 expected 66 survival 66 relat ed 66 to 66 heart 66 failure 66 or 66 other 66 comorbidities 66 is 66 less 66 than 66 1- 266 years, 66 since 66 a 66 defibrillator 66 will 66 not 66 improve 66 their 66 survival.Changing 66 from 66 me toprolol 66 succinate 66 to 66 metoprolol 66 tartrate 66 will 66 not 66 be 66 beneficial 66 since 66 the 66 succi nate 66 form 66 is 66 the 66 preferred 66 formulation 66 for 66 heart 66 failure. 66 Nondihydropyridine 66 cal cium 66 channel 66 blockers 66 reduce 66 the 66 ejection 66 fraction 66 and 66 would 66 therefore 66 not 66 b e 66 beneficial 66 in 66 this 66 patient. 66 Patients 66 with 66 severe 66 heart 66 failure 66 and 66 severe 66 chr onic 66 kidney 66 disease 66 generally 66 do 66 not 66 respond 66 favorably 66 to 66 thiazide 66 diuretics. You 66 see 66 a 66 58-year- old 66 male 66 for 66 a 66 routine 66 examination. 66 According 66 to 66 the 66 American 66 College 66 of 66 C ardiology/ American 66 Heart 66 Association 66 classification 66 system, 66 which 66 one 66 of 66 the 66 following 66 would 66 meet 66 the 66 criteria 66 for 66 stage 66 B 66 heart 66 failure, 66 assuming 66 he 66 has 66 no 66 additi onal 66 complications? A 66 history 66 of 66 dyspnea 66 on 66 exertion Well 66 compensated 66 heart 66 failure A 66 grade 66 2/6 66 apical 66 holosystolic 66 murmur 66 radiating 66 to 66 the 66 axilla Uncontrolled 66 type 66266 diabetes 66 - 66 answer--C A 66 significant 66 heart 66 murmur, 66 such 66 as 66 a 66 grade 66 2/6 66 apical 66 holosystolic 66 murmur 66 that 66 radiates 66 to 66 the 66 axilla, 66 is 66 generally 66 meaningful. 66 The 66 American 66 College 66 of 6 6 Cardiology/ American 66 Heart 66 Association 66 classification 66 of 66 heart 66 failure 66 includes 66 four 66 stages. 6 6 Stage 66 A 66 is 66 defined 66 as 66 the 66 absence 66 of 66 structural 66 disease 66 in 66 a 66 patient 66 at 66 hi gh 66 risk 66 for 66 the 66 development 66 of 66 heart 66 failure. 66 This 66 includes 66 patients 66 with 66 hype rtension, 66 atherosclerotic 66 disease, 66 diabetes 66 mellitus, 66 obesity, 66 metabolic 66 syndrome , 66 or 66 a 66 family 66 history 66 of 66 cardiomyopathy, 66 as 66 well 66 as 66 those 66 using 66 cardiotoxins. 66 Patients 66 with 66 stage 66 B 66 heart 66 failure 66 have 66 evidence 66 of 66 structural 66 heart 66 diseas e, 66 such 66 as 66 a 66 previous 66 myocardial 66 infarction, 66 asymptomatic 66 valvular 66 disease, 66 o r 66 evidence 66 of 66 left 66 ventricular 66 remodeling 66 such 66 as 66 left 66 ventricular 66 hypertrophy 66 or 66 a 66 low 66 ejection 66 fraction. 66 Any 66 patient 66 with 66 structural 66 heart 66 disease 66 is 66 at 66 ris k 66 of 66 heart 66 failure 66 and 66 should 66 be 66 managed 66 aggressively 66 to 66 prevent 66 complicati ons 66 in 66 the 66 future.Stage 66 C 66 is 66 defined 66 as 66 structural 66 heart 66 disease 66 with 66 prior 66 o r 66 current 66 symptoms 66 of 66 heart 66 failure. 66 Patients 66 with 66 stage 66 D 66 heart 66 failure 66 have 66 refractory 66 heart 66 failure 66 requiring 66 specialized 66 interventions. A 66 61-year- old 66 male 66 sees 66 you 66 for 66 a 66 routine 66 annual 66 evaluation. 66 A 66 review 66 of 66 systems 66 is 6 6 notable 66 only 66 for 66 nocturia 66 1-2 66 times 66 per 66 night. 66 He 66 has 66 a 66 history 66 of 66 a 66 non- ST-elevation 66 myocardial 66 infarction 66266 years 66 ago 66 treated 66 with 66 a 66 drug-
her 66 weight 66 is 66 more 66 than 66366 lb 66 over 66 her 66 target 66 weight 66 of 6613066 lb.Which 66 one 66 of 66 the 66 following 66 is 66 the 66 most 66 common 66 reason 66 for 66 medication 66 nonadherence 66 in 6 6 patients 66 such 66 as 66 this? Cost Concerns 66 regarding 66 potential 66 side 66 effects Conflicting 66 instructions 66 from 66 different 66 health 66 care 66 providers Failure 66 to 66 understand 66 - 66 answer--D Medication 66 compliance 66 and 66 understanding 66 of 66 how 66 and 66 why 66 to 66 take 66 medicatio ns 66 is 66 a 66 crucial 66 aspect 66 of 66 medical 66 care 66 in 66 heart 66 failure. 66 A 66 study 66 of 66 patients 66 recently 66 discharged 66 from 66 the 66 hospital 66 following 66 an 66 exacerbation 66 of 66 heart 66 failur e 66 found 66 a 66 high 66 rate 66 of 66 medication 66 nonadherence, 66 with 66 only 66 one- third 66 of 66 patients 66 taking 66 all 66 their 66 medications 66 as 66 prescribed 66 and 66 not 66 taking 66 un prescribed 66 medications. 66 Of 66 those 66 not 66 taking 66 medications 66 as 66 prescribed, 66 the 66 m ost 66 common 66 reason 66 given 66 was 66 not 66 understanding 66 discharge 66 instructions 66 (57%)
. 66 Less 66 common 66 reasons 66 include 66 confusion 66 due 66 to 66 conflicting 66 instructions 66 from 66 the 66 discharging 66 physician 66 and 66 the 66 primary 66 care 66 physician, 66 medication 66 cost, 66 being 66 unconvinced 66 of 66 the 66 utility 66 of 66 the 66 medication, 66 and 66 concerns 66 regarding 66 p otential 66 side 66 effects 66 (SOR 66 B). Which 66 one 66 of 66 the 66 following 66 is 66 true 66 regarding 66 the 66 use 66 of 66 clopidogrel 66 (Plavix) 66 with 66 aspirin 66 in 66 patients 66 with 66 coronary 66 artery 66 disease? A 66 loading 66 dose 66 of 6615066 mg 66 of 66 clopidogrel 66 is 66 recommended 66 at 66 the 66 time 66 acute 66 coronary 66 syndrome 66 is 66 diagnosed Clopidogrel 66 should 66 be 66 given 66 first 66 because 66 it 66 has 66 a 66 faster 66 onset 66 of 66 antiplatele t 66 activity Clopidogrel 66 should 66 be 66 discontinued 66 at 66 least 66566 days 66 before 66 coronary 66 artery 66 by pass 66 graft 66 surgery 66 and 66 aspirin 66 should 66 be 66 continued 66 up 66 to 66 the 66 day 66 of 66 surger y When 66 used 66 with 66 clopidogrel, 66 aspirin 66 can 66 be 66 given 66 at 66 a 66 dosage 66 of 6632566 mg 66 daily 66 after 66 cardiac 66 stent 66 placement 66 - 66 answer--C Clopidogrel 66 should 66 be 66 discontinued 66 at 66 least 66566 days 66 before 66 coronary 66 bypass 66 s urgery 66 but 66 aspirin 66 should 66 be 66 continued. 66 Clopidogrel 66 is 66 a 66 thienopyridine 66 derivat ive 66 that 66 is 66 used 66 primarily 66 as 66 an 66 adjunctive 66 agent 66 in 66 patients 66 with 66 acute 66 coro nary 66 syndrome 66 (ACS). 66 It 66 is 66 used 66 most 66 commonly 66 in 66 conjunction 66 with 66 aspirin 66 but 66 is 66 an 66 adequate 66 alternative 66 in 66 patients 66 who 66 are 66 aspirin 66 intolerant. 66 If 66 clopid ogrel 66 is 66 used 66 alone, 66 initial 66 treatment 66 with 66 heparin 66 or 66 possibly 66 with 66 a 66 glycopro tein 66 IIb/ IIIa 66 inhibitor 66 is 66 especially 66 important 66 because 66 of 66 clopidogrel's 66 delayed 66 onset 66 of 6 6 antiplatelet 66 activity 66 compared 66 to 66 that 66 of 66 aspirin. 66 The 66 CAPRIE 66 trial 66 (Clopidogre
l 66 versus 66 Aspirin 66 in 66 Patients 66 at 66 Risk 66 of 66 Ischaemic 66 Events) 66 found 66 clopidogrel 66 t o 66 be 66 comparable 66 to 66 aspirin 66 in 66 reducing 66 ischemic 66 events 66 in 66 patients 66 with 66 a 66 h istory 66 of 66 recent 66 myocardial 66 infarction, 66 recent 66 stroke, 66 or 66 symptomatic 66 peripheral 6 6 artery 66 disease. 66 The 66 CURE 66 trial 66 (Clopidogrel 66 in 66 Unstable 66 angina 66 to 66 prevent 66 R ecurrent 66 Events) 66 found 66 the 66 combination 66 of 66 aspirin 66 and 66 clopidogrel 66 to 66 be 66 mor e 66 effective 66 in 66 reducing 66 ischemic 66 events 66 than 66 aspirin 66 alone 66 in 66 patients 66 with 66 A CS.Clopidogrel 66 should 66 be 66 started 66 with 66 a 66 loading 66 dose 66 of 66 300- 60066 mg, 66 followed 66 by 667566 mg 66 daily. 66 When 66 clopidogrel 66 is 66 used 66 with 66 aspirin, 66 th e 66 aspirin 66 dosage 66 should 66 be 66 75- 16266 mg 66 daily. 66 Because 66 of 66 an 66 increased 66 risk 66 of 66 bleeding, 66 current 66 guidelines 66 r ecommend 66 that 66 clopidogrel 66 be 66 discontinued 66 at 66 least 66566 days, 66 and 66 preferably 667 66 days, 66 before 66 bypass 66 graft 66 surgery. 66 In 66 patients 66 undergoing 66 urgent 66 cardiac 66 cat heterization 66 and 66 percutaneous 66 coronary 66 intervention 66 (PCI), 66 a 66 loading 66 dose 66 of 66 60066 mg 66 of 66 clopidogrel 66 should 66 be 66 administered 66 either 66 before 66 or 66 at 66 the 66 time 66 of 66 the 66 PCI. 66 Clopidogrel 66 should 66 be 66 continued 66 at 66 a 66 dosage 66 of 667566 mg 66 daily, 66 a long 66 with 66 aspirin. A 66 68-year- old 66 male 66 with 66 a 66 history 66 of 66 hypertension, 66 diabetes 66 mellitus, 66 and 66 heart 66 failure 66 presents 66 with 66 a 66 6- week 66 history 66 of 66 progressive 66 fatigue, 66 ankle 66 swelling, 66 and 66 dyspnea 66 on 66 exertion. 6 6 His 66 current 66 medications 66 include 66 lisinopril 66 (Prinivil, 66 Zestril), 662066 mg 66 daily; 66 atorva statin 66 (Lipitor), 664066 mg 66 daily; 66 insulin 66 glargine 66 (Lantus), 661066 U 66 subcutaneously 66 a t 66 bedtime; 66 and 66 sitagliptin 66 (Januvia), 6610066 mg 66 daily.On 66 examination 66 his 66 pulse 66 r ate 66 is 667666 beats/ min 66 and 66 regular, 66 and 66 his 66 blood 66 pressure 66 is 66 130/80 66 mm 66 Hg. 66 He 66 has 66 jugular 6 6 venous 66 distention, 66 a 66 laterally 66 displaced 66 apex 66 beat, 66 and 66 1+ 66 pitting 66 ankle 66 ede ma. 66 Lung 66 auscultation 66 reveals 66 bibasilar 66 crackles. 66 Cardiac 66 auscultation 66 reveals 66 a 66 regular 66 rhythm 66 with 66 a 66 soft 66 S4. 66 Echocardiography 66 shows 66 a 66 left 66 ventricular 66 ejection 66 fraction 66 of 66 40%. 66 A 66 basic 66 metabolic 66 panel 66 is 66 normal, 66 including 66 a 66 crea tinine 66 level 66 of 66 1.1. 66 mg/dL 66 (N 66 0.7- 1.3).Which 66 one 66 of 66 the 66 following 66 should 66 be 66 started 66 at 66 this 66 time? Carvedilol 66 (C 66 - 66 answer--B This 66 patient 66 has 66 signs 66 of 66 heart 66 failure 66 with 66 fluid 66 retention. 66 Euvolemic 66 status 66 should 66 be 66 attained 66 first 66 in 66 patients 66 with 66 fluid 66 overload. 66 Diuretics 66 produce 66 sym ptomatic 66 benefits 66 more 66 rapidly 66 than 66 any 66 other 66 drug 66 for 66 heart 66 failure 66 and 66 are 6 6 the 66 only 66 agents 66 that 66 can 66 adequately 66 control 66 fluid 66 retention. 66 Loop 66 diuretics, 66 s uch 66 as 66 furosemide, 66 are 66 more 66 effective 66 than 66 thiazide 66 diuretics 66 for 66 controlling 66 s odium 66 and 66 free 66 water 66 clearance 66 (SOR 66 C).Although 66 β- blockers 66 should 66 generally 66 be 66 prescribed 66 for 66 all 66 patients 66 with 66 heart 66 failure, 66 the y 66 should 66 not 66 be 66 started 66 in 66 patients 66 with 66 a 66 current 66 or 66 recent 66 history 66 of 66 fluid 6 6 retention 66 unless 66 the 66 patient 66 is 66 also 66 on 66 a 66 diuretic. 66 Furthermore, 66 treatment 66 wit h 66 a 66 β- blocker 66 should 66 be 66 initiated 66 at 66 very 66 low 66 doses 66 (e.g., 66 carvedilol, 66 3.125 66 mg 66 twic
raction), 66 disease 66 severity 66 such 66 as 66 New 66 York 66 Heart 66 Association 66 class, 66 related 6 6 comorbidities 66 such 66 as 66 renal 66 dysfunction, 66 or 66 other 66 characteristics 66 such 66 as 66 age 66 or 66 ethnicity. 66 Because 66 sodium 66 intake 66 is 66 typically 66 high 66 (>4 66 g/ d) 66 in 66 the 66 general 66 population, 66 clinicians 66 should 66 consider 66 some 66 degree 66 of 66 sodi um 66 restriction, 66 su A 66 76-year-old 66 female 66 sees 66 you 66 for 66 follow- up 66266 weeks 66 after 66 she 66 was 66 hospitalized 66 for 66 heart 66 failure. 66 Her 66 past 66 medical 66 hi story 66 is 66 notable 66 for 66 heart 66 failure, 66 hypertension, 66 coronary 66 heart 66 disease, 66 and 66 well 66 controlled 66 depression. 66 She 66 does 66 not 66 smoke. 66 Her 66 current 66 medications 66 incl ude 66 the 66 following:Lisinopril 66 (Prinivil, 66 Zestril), 662066 mg 66 dailyHydrochlorothiazide, 6625 66 mg 66 dailyFurosemide 66 (Lasix), 664066 mg 66 dailyMetoprolol 66 succinate 66 (Toprol- XL), 665066 mg 66 dailyMetformin 66 (Glucophage), 6685066 mg 66 twice 66 dailySimvastatin 66 (Zoco r), 664066 mg 66 dailyCitalopram 66 (Celexa), 662066 mg 66 dailyAspirin, 668166 mg 66 dailyOn 66 exam ination, 66 the 66 patient 66 is 66 afebrile, 66 her 66 blood 66 pressure 66 is 66 130/82 66 mm 66 Hg, 66 her 66 pu lse 66 rate 66 is 669066 beats/min, 66 and 66 her 66 respiratory 66 rate 66 is 66 20/ min. 66 Her 66 jugular 66 veins 66 are 66 mildly 66 distended. 66 Examination 66 of 66 the 66 lungs 66 reveals 66 bibasilar 66 crackles. 66 The 66 cardiac 66 examination 66 reveals 66 a 66 regular 66 rhythm, 66 an 66 S 66 gallop, 66 and 66 no 66 murmurs. 66 She 66 has 66 1+ 66 bilateral 66 edema 66 to 66 the 66 shins. 66 A 66 lab 6 6 - 66 answer--D Hyponatremia 66 is 66 a 66 common 66 problem 66 in 66 patients 66 with 66 heart 66 failure, 66 and 66 its 66 se verity 66 correlates 66 directly 66 with 66 the 66 degree 66 of 66 myocardial 66 dysfunction. 66 Hypervole mic 66 hyponatremia 66 is 66 the 66 type 66 most 66 commonly 66 associated 66 with 66 heart 66 failure, 66 with 66 edema 66 indicating 66 increased 66 total 66 body 66 sodium 66 and 66 water. 66 Heart 66 failure 66 i s 66 associated 66 with 66 inappropriately 66 elevated 66 plasma 66 arginine 66 vasopressin 66 levels, 6 6 which 66 causes 66 impaired 66 water 66 excretion, 66 a 66 dilutional 66 hyponatremia, 66 and 66 increa sed 66 ventricular 66 preload. 66 Management 66 generally 66 calls 66 for 66 a 66 reduction 66 in 66 water 66 intake 66 and 66 improving 66 cardiac 66 function.All 66 SSRIs 66 such 66 as 66 citalopram 66 are 66 assoc iated 66 with 66 a 66 high 66 incidence 66 of 66 hyponatremia, 66 and 66 elderly 66 patients 66 may 66 be 66 at 66 increased 66 risk 66 for 66 this 66 side 66 effect. 66 Physicians 66 caring 66 for 66 elderly 66 patients 66 sho uld 66 be 66 aware 66 of 66 this 66 potentially 66 serious 66 but 66 reversible 66 adverse 66 effect.Thiazide 6 6 diuretics 66 are 66 associated 66 with 66 impaired 66 renal 66 water 66 excretion, 66 and 66 reducing 66 th e 66 dosage 66 of 66 thiazide 66 diuretics 66 or 66 discontinuing 66 their 66 use 66 is 66 recommended. 66 Alt hough 66 increasing 66 sodium 66 and 66 water 66 intake 66 is 66 the 66 primary 66 treatment 66 for 66 hypo volemic 66 hyponatremia, 66 patients 66 with 66 heart 66 failure 66 do 66 not 66 benefit 66 from 66 this 66 stra tegy. 66 Desmopressin 66 is 66 a 66 vasopressin 66 analog 66 and 66 is 66 contraindicated 66 in 66 patient s 66 with 66 hyponatremia. 66 Arginine 66 vasopressin 66 antagonists, 66 including 66 tolvaptan 66 and 6 6 conivaptan, 66 can 66 be 66 considered 66 for 66 patients 66 with 66 severe 66 or 66 recalcitrant 66 hypon atremia. A 66 57-year- old 66 male 66 with 66 a 66 history 66 of 66 chronic 66 stable 66 angina 66 and 66 type 66266 diabetes 66 prese nts 66 with 66 a 66 recent 66 increase 66 in 66 symptoms. 66 An 66 EKG 66 is 66 notable 66 for 66 the 66 presenc e 66 of 66 first 66 degree 66 AV 66 block 66 and 66 left 66 anterior 66 hemiblock. 66 Coronary 66 angiography 66 reveals 66 three-
vessel 66 disease 66 with 66 a 66 left 66 ventricular 66 ejection 66 fraction 66 of 66 45%.Which 66 one 66 of 66 t he 66 following 66 interventions 66 would 66 offer 66 the 66 greatest 66 survival 66 benefit? Intensive 66 medical 66 management A 66 permanent 66 pacemaker An 66 implantable 66 cardiac 66 defibrillator Percutaneous 66 coronary 66 intervention Coronary 66 artery 66 bypass 66 graft 66 surgery 66 - 66 answer--E Angiographic 66 characteristics 66 of 66 high- risk 66 groups 66 with 66 improved 66 survival 66 after 66 surgical 66 management 66 include 66 left 66 mai n 66 coronary 66 artery 66 stenosis, 66 three- vessel 66 disease 66 with 66 a 66 left 66 ventricular 66 ejection 66 fraction 66 <50%, 66 and 66 two- 66 or 66 three- vessel 66 disease 66 with 66 >75% 66 stenosis 66 of 66 the 66 proximal 66 left 66 anterior 66 descending 66 a rtery 66 (LAD).A 66 meta-analysis 66 of 66 three 66 major 66 trials 66 confirmed 66 the 66 10- year 66 survival 66 benefit 66 from 66 surgery 66 for 66 patients 66 with 66 three-vessel 66 disease, 66 two- vessel 66 disease, 66 and 66 single- vessel 66 disease 66 that 66 included 66 stenosis 66 of 66 the 66 proximal 66 LAD, 66 regardless 66 of 66 wh ether 66 the 66 patient 66 had 66 a 66 normal 66 or 66 abnormal 66 left 66 ventricular 66 ejection 66 fraction. 66 Large 66 randomized 66 trials 66 that 66 have 66 reached 66 7-8 66 years 66 of 66 follow- up 66 have 66 generally 66 shown 66 that 66 survival 66 for 66 patients 66 with 66 diabetes 66 mellitus 66 is 66 better 66 with 66 coronary 66 artery 66 bypass 66 (CABG) 66 surgery 66 than 66 with 66 percutaneous 66 c oronary 66 intervention 66 (PCI). 66 The 66 patient 66 described 66 does 66 not 66 have 66 an 66 indication 66 for 66 the 66 placement 66 of 66 either 66 an 66 implantable 66 cardiac 66 defibrillator 66 or 66 a 66 pacema ker, 66 given 66 that 66 his 66 ejection 66 fraction 66 is 66 >35% 66 and 66 he 66 does 66 not 66 have 66 complet e 66 heart 66 block.Patients 66 who 66 have 66 diabetes 66 with 66 significant 66 two- 66 or 66 three- vessel 66 disease 66 or 66 those 66 with 66 single- vessel 66 proximal 66 LAD 66 or 66 left 66 main 66 disease 66 generally 66 do 66 better 66 with 66 coronary 66 artery 66 bypass 66 than 66 with 66 percutaneous 66 intervention. 66 A 66 study 66 of 66313166 patients 66 showed 66 that 66 at 66566 years 66 or 66 the 66 longest 66 follow- up, 66 patients 66 with 66 diabetes 66 randomized 66 to 66 CABG 66 had 66 a 66 lower 66 all- cause 66 mortality 66 rate 66 than 66 those 66 randomized 66 to 66 PCI 66 with 66 either 66 a 66 drug- eluting 66 stent 66 or 66 a 66 bare 66 metal 66 stent 66 (relative 66 risk 66 = 66 0.67; 66 P 66 = 66 0.002). 66 There 6 6 is 66 a 66 higher 66 risk 66 of 66 stroke 66 with 66 CABG 66 than 66 with 66 PCI. An 66 otherwise 66 healthy 66 53-year- old 66 male 66 presents 66 with 66 episodes 66 of 66 substernal 66 chest 66 pain 66 that 66 occur 66 both 66 at 66 rest 66 and 66 with 66 exertion. 66 His 66 father 66 had 66 a 66 myocardial 66 infarction 66 at 66 age 66 58. 66 A 66 resting 66 EKG 66 shows 66 a 66 right 66 bundle 66 branch 66 block. 66 A 66 potassium 66 level 66 and 66 h emoglobin 66 level 66 are 66 both 66 normal.Which 66 one 66 of 66 the 66 following 66 would 66 be 66 the 66 m ost 66 appropriate 66 next 66 step 66 to 66 evaluate 66 this 66 patient 66 for 66 coronary 66 artery 66 disease ? Transthoracic 66 echocardiography Coronary 66 CT Adenosine 66 myocardial 66 perfusion 66 imaging
Hyponatremia 66 and 66 elevation 66 of 66 serum 66 transaminases 66 may 66 occur 66 with 66 heart 66 fai lure, 66 due 66 to 66 chronic 66 passive 66 congestion 66 of 66 the 66 liver 66 and 66 expansion 66 of 66 total 66 body 66 water 66 under 66 the 66 influence 66 of 66 vasopressin. 66 Elevation 66 of 66 creatinine 66 kinase 6 6 occurs 66 in 66 the 66 setting 66 of 66 acute 66 coronary 66 syndrome 66 but 66 would 66 not 66 be 66 expecte d 66 in 66 heart 66 failure 66 by 66 itself. 66 BNP 66 is 66 typically 66 elevated 66 in 66 patients 66 with 66 sympto matic 66 heart 66 failure. Cardioselective 66 β- blockers 66 are 66 contraindicated 66 in 66 patients 66 with 66 which 66 one 66 of 66 the 66 following? Moderate 66 persistent 66 asthma Hypertension Hyperthyroidism Raynaud's 66 phenomenon Supraventricular 66 tachycardia 66 - 66 answer--D β- Blockers 66 are 66 helpful 66 for 66 controlling 66 symptoms 66 of 66 hyperthyroidism 66 and 66 the 66 vent ricular 66 rate 66 in 66 patients 66 with 66 supraventricular 66 tachycardia 66 if 66 they 66 are 66 not 66 compl icated 66 by 66 other 66 conditions. 66 Although 66 recent 66 research 66 is 66 controversial, 66 β- blockers 66 can 66 increase 66 the 66 frequency 66 of 66 symptoms 66 in 66 patients 66 with 66 Raynaud's 6 6 phenomenon 66 and 66 generally 66 should 66 be 66 avoided 66 unless 66 absolutely 66 needed 66 for 66 other 66 concomitant 66 medical 66 conditions.Current 66 data 66 suggests 66 that 66 the 66 risk 66 of 66 a sthma 66 being 66 worsened 66 by 66 systemic 66 nonselective 66 β- blockers 66 outweighs 66 any 66 potential 66 benefits 66 they 66 may 66 have 66 for 66 other 66 clinical 66 pr oblems. 66 Recent 66 studies 66 have 66 shown 66 that 66 systemic 66 cardioselective 66 β- blockers, 66 on 66 the 66 other 66 hand, 66 are 66 not 66 associated 66 with 66 a 66 significant 66 increased 66 risk 66 of 66 moderate 66 or 66 severe 66 asthma 66 exacerbations. 66 Nonselective 66 β- blockers 66 should 66 not 66 be 66 prescribed 66 for 66 patients 66 with 66 asthma, 66 but 66 cardioselectiv e 66 β- blockers, 66 preferably 66 in 66 low 66 doses, 66 may 66 be 66 used 66 when 66 strongly 66 indicated 66 and 6 6 other 66 therapeutic 66 options 66 are 66 not 66 available. A 66 58-year- old 66 female 66 with 66 heart 66 failure 66 has 66 an 66 ejection 66 fraction 66 of 66 45%. 66 She 66 is 66 current ly 66 asymptomatic 66 and 66 her 66 medications 66 include 66 lisinopril 66 (Prinivil, 66 Zestril), 664066 mg 66 daily; 66 carvedilol 66 (Coreg), 66 6.25 66 mg 66 twice 66 daily; 66 and 66 furosemide 66 (Lasix), 664066 m g 66 daily. 66 Her 66 blood 66 pressure 66 is 66 128/84 66 mm 66 Hg 66 and 66 her 66 pulse 66 rate 66 is 667466 be ats/ min. 66 She 66 has 66 no 66 edema 66 on 66 examination 66 and 66 her 66 lungs 66 are 66 clear. 66 Laborator y 66 testing 66 shows 66 a 66 slightly 66 elevated 66 pro- BNP 66 level.Which 66 one 66 of 66 the 66 following 66 would 66 be 66 most 66 appropriate 66 at 66 this 66 tim e? Increase 66 the 66 dosage 66 of 66 carvedilol 66 to 66 12.5 66 mg 66 twice 66 daily Stop 66 lisinopril 66 and 66 start 66 ramipril 66 (Altace), 661066 mg 66 daily
Start 66 losartan 66 (Cozaar), 665066 mg 66 daily Start 66 metolazone, 66566 mg 66 three 66 times 66 a 66 week Start 66 spironolactone 66 (Aldactone), 662566 mg 66 twice 66 daily 66 - 66 answer--A The 66 patient 66 is 66 on 66 a 66 very 66 low 66 dosage 66 of 66 carvedilol. 66 Maximizing 66 the 66 dosage 66 of 66 β- blockers 66 is 66 crucial 66 in 66 heart 66 failure 66 treatment 66 and 66 should 66 be 66 considered 66 even 6 6 if 66 the 66 patient 66 is 66 asymptomatic 66 and 66 vital 66 signs 66 are 66 normal. 66 Guidelines 66 recom mend 66 that 66 patients 66 who 66 have 66 heart 66 failure 66 with 66 reduced 66 ejection 66 fraction 66 sho uld 66 have 66 their 66 medical 66 therapy 66 titrated 66 to 66 target 66 dosages.Adding 66 metolazone 66 i s 66 not 66 necessary 66 unless 66 the 66 heart 66 failure 66 has 66 been 66 refractory 66 to 66 the 66 use 66 of 66 a 66 loop 66 diuretic. 66 Metolazone 66 can 66 also 66 cause 66 significant 66 potassium 66 wasting 66 and 66 should 66 be 66 used 66 with 66 caution, 66 especially 66 in 66 patients 66 currently 66 on 66 loop 66 diureti cs.Spironolactone 66 has 66 a 66 long 66 half-life 66 so 66 twice- daily 66 dosing 66 is 66 not 66 recommended 66 because 66 it 66 may 66 increase 66 hyperkalemia 66 with out 66 adding 66 any 66 benefit. 66 Dosages 66 greater 66 than 662566 mg 66 daily 66 are 66 not 66 recomme nded 66 for 66 heart 66 failure.Losartan 66 should 66 not 66 be 66 added 66 because 66 trials 66 have 66 sho wn 66 worse 66 outcomes 66 when 66 an 66 angiotensin 66 receptor 66 blocker 66 (ARB) 66 is 66 added 66 t o 66 an 66 ACE 66 inhibitor. 66 Patients 66 who 66 cannot 66 tolerate 66 an 66 ACE 66 inhibitor 66 should 66 be 66 switched 66 to 66 an 66 ARB 66 but 66 this 66 patient 66 is 66 tolerating 66 the 66 ACE 66 inhibitor. 66 It 66 is 66 more 66 useful 66 to 66 add 66 or 66 maximize 66 β- blocker 66 therapy 66 with 66 either 66 an 66 ACE 66 inhibitor 66 or 66 an 66 ARB, 66 rather 66 than 66 to 66 com bine 66 all 66 three 66 types 66 of 66 agents. 66 This 66 patient's 66 lisinopril 66 dosage 66 is 66 already 66 at 66 t he 66 target 66 level 66 and 66 she 66 is 66 tolerating 66 it 66 so 66 there 66 is 66 no 66 reason 66 to 66 switch 66 to 66 another 66 ACE 66 inhibitor. A 66 63-year- old 66 male 66 was 66 recently 66 diagnosed 66 with 66 moderate 66 obstructive 66 sleep 66 apnea. 66 He 6 6 reports 66 daytime 66 drowsiness 66 and 66 says 66 that 66 he 66 has 66 become 66 progressively 66 mor e 66 fatigued. 66 He 66 has 66 known 66 heart 66 failure 66 that 66 has 66 resulted 66 in 66 three 66 prior 66 hosp ital 66 admissions, 66 but 66 he 66 has 66 remained 66 stable 66 over 66 the 66 past 66666 months. 66 He 66 as ks 66 you 66 about 66 continuous 66 positive 66 airway 66 pressure 66 (CPAP) 66 therapy.Which 66 one 66 of 66 the 66 following 66 would 66 be 66 the 66 most 66 appropriate 66 advice 66 regarding 66 CPAP 66 thera py 66 for 66 this 66 patient? It 66 is 66 associated 66 with 66 a 66 significant 66 risk 66 of 66 arrhythmia 66 in 66 patients 66 with 66 heart 66 fai lure It 66 is 66 associated 66 with 66 a 66 significant 66 risk 66 of 66 increased 66 edema 66 in 66 patients 66 with 66 h eart 66 failure It 66 will 66 have 66 no 66 effect 66 on 66 his 66 heart 66 failure 66 but 66 is 66 indicated 66 to 66 help 66 his 66 sleep 66 apnea 66 symptoms It 66 will 66 likely 66 improve 66 his 66 heart 66 function 66 in 66 addition 66 to 66 improving 66 symptoms 66 rel ated 66 to 66 his 66 sleep 66 apnea 66 - 66 answer--D Sleep 66 apnea 66 is 66 an 66 important 66 commonly 66 unrecognized 66 cause 66 of 66 heart 66 failure. 66 Continuous 66 positive 66 airway 66 pressure 66 (CPAP) 66 therapy 66 has 66 been 66 shown 66 to 66 impr
