Posts: 3,675,937
Threads: 734,344
Joined:
Sep 2021
Reputation:
5
A 69-year-old woman with a history of severe asthma is brought to the emergency department by her daughter because of severe lightheadedness. The patient also complains of worsening shortness of breath and progressive fatigue over the last year. For the last three months, the patient is able to walk only 2 to 3 blocks before developing a profound shortness of breath. She recently started using three pillows for sleep during the night. She denies chest pain and diaphoresis. The patient's daughter states that three weeks ago, her mother had a syncopal episode that lasted for two minutes on her way to the supermarket. At that time, she did not seek medical attention. The patient's current medications include lisinopril, digoxin, and furosemide.
In the emergency room, her heart rate is 102/min, blood pressure is 115/70 mm Hg, and respiratory rate is 22/min. Physical examination reveals jugulovenous distension and bibasilar crackles. Heart auscultation demonstrates a diminished S1, a loud P2, and an S3 gallop. There is a 1+ pitting edema of both extremities. EKG shows normal sinus rhythm with several multifocal premature contractions (PVCs) and a four-beat run of ventricular tachycardia (VT) at a rate of 128/min. The echocardiogram reveals an ejection fraction below 25% and no evidence of aortic stenosis. The patient is admitted to the telemetry unit, and recordings show PVCs and 12 runs of nonsustained VT of 4 to 18 beats in duration during the first day.
Which of the following is the most appropriate management at this time?
(A) Increase the dose of digoxin
(B) Start metoprolol
© Start amiodarone
(D) Cardiac catheterization
(E) Perform electrophysiologic study
Posts: 3,675,937
Threads: 734,344
Joined:
Sep 2021
Reputation:
5
can some learned soul comment on how to approach the case i mean the cardiac findings...pvc? four beat vt?.....please exp yur answers..thx
Posts: 3,675,937
Threads: 734,344
Joined:
Sep 2021
Reputation:
5
any body explain this please
Posts: 3,675,937
Threads: 734,344
Joined:
Sep 2021
Reputation:
5
This 69-year-old woman with nonischemic cardiomyopathy has presyncopal and syncopal episodes most likely caused by nonsustained ventricular tachycardia. She is at a high risk for death from a cardiac arrhythmia and should be placed on amiodarone, which is effective in reducing this risk. Beta-blockers also can be beneficial in reducing the risk of cardiac arrhythmias; however, this patient has a history of severe asthma. Therapy with beta-blockers would not be the best choice. Although intravenous loading with amiodarone is not necessary at this time, oral loading is appropriate. Cardiogenic syncope can occur on a mechanical or arrhythmic basis. Mechanical problems that can cause syncope include aortic stenosis, pulmonary stenosis, and hypertrophic obstructive cardiomyopathy. Episodes are commonly exertional or postexertional. Neurological causes of syncope are far less common and less dangerous than are cardiac causes. Increasing the dose of digoxin will not change the risk of developing a ventricular dysthymia. Electrophysiolocal studies should be performed in patients in whom the syncope seems to be of a cardiac etiology and a definite cause cannot be found. This patient already has VT documented on the EKG. Electrophysiological studies are also done to see if the patient needs an implantable defibrillator, but this would not be the most appropriate next best step
