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A 65-year-old woman with a past medical history of congestive heart failure (CHF) presents with shortness of breath for one day. On further questioning, the patient describes waking in the night unable to breathe. She has been using three pillows to sleep for the past month. She has been hospitalized for this problem twice in the past year and has been noncompliant with her medications, which are furosemide, lisinopril, metoprolol, and aspirin. Physical examination shows: temperature 99 F, respiratory rate 26/min, blood pressure 180/100 mm Hg, and pulse 72/min. Jugulovenous distension is present, as well as an S3 gallop, a III/VI systolic murmur radiating to the axilla, and a displaced point of maximal impulse. The lungs have rales bilaterally, and there is a 2+ pitting edema of the extremities. The BUN is 29 mg/dL, and the creatinine is 1.4 mg/dL.
You treat the patient with intravenous diuretics, nitrates, and morphine. One day after the hospitalization, she is much improved and is ready to be discharged. Which of the following is most likely to decrease mortality in this patient?
(A) Adding irbesartan
(B) Spironolactone
© Hydralazine and isosorbide dinitrate
(D) Dobutamine
(E) Amlodipine
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its BBBB,ace inhi,beta blocker,spironolactone decrease mortality in chf
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(B) Spironolactone
Explanation:
Angiotensin-receptor blockers, such as losartan, irbesartan, candesartan, or telmisartan, are used predominantly in patients who cannot tolerate ACE inhibitors because of cough. Angiotensin-receptor blockers will not definitely lower mortality when added to a patient already on ACE inhibitors. Hydralazine and nitrates lower mortality but not as much as the ACE inhibitors. Dobutamine is a positive inotrope that can be used to acutely manage patients with severe, acute exacerbations of congestive failure, such as pulmonary edema. There is no definite evidence that it lowers mortality, and it is a temporary measure for acutely unstable patients who do not respond well to initial therapy with diuretics, oxygen, nitrates, and morphine. Amlodipine is a calcium-channel blocker that does not reliably lower mortality. Spirinolactone helps block the renin-angiotensin system and has been definitely shown to lower mortality in CHF when used on a long-term basis.
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Adding ACEi inhibitor will decrease mortality in pts with heat failure.
But pts with symptomatic MR should go valve replacement.
there is little date about ACEi in MR.
I ll pick up B.
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Mortality in CHF is decreased by 3 drugs:
ACEI/ARB
spironolactone
beta-blockers
ACEI/ARB are recommended for all patients with CHF, I would go with A.
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one more point favour to ans ..
regarding irbesartan:
A large randomized trial following 4100+ men and women with heart failure and normal ejection fraction (>=45%) over 4+ years found no improvement in study outcomes or survival with irbesartan as compared to placebo
from wiki
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ohh i didnt look,that s pt already on ACEI...
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