06-05-2010, 10:25 PM
(E) Start the patient on carvedilol
Explanation:
This patient has congestive heart failure (CHF) due to diastolic dysfunction secondary to chronic hypertension, with no mention of left ventricular (LV) systolic dysfunction. Diastolic dysfunction is more common in elderly, hypertensive patients. Signs of pulmonary or venous congestion in patients with a LV chamber of normal size indicate diastolic dysfunction. The hypertrophic, stiff left ventricle needs more time to fill during diastole, so treatment with beta-blockers helps in slowing the heart rate and increasing cardiac output. Even though he has asthma, his is not wheezing now, and so it would be best to decrease his mortality with beta-blockers. Diuretics and nitrates should be used with caution because the decrease in preload may decrease cardiac output and cause hypotension. The use of increased diuretics is helpful in volume-overloaded patients for relief of severe edema, which is not present in this case. Reassurance, dietary modification alone, and rescheduling a return appointment is not an option in this symptomatic patient. ACE inhibitors are more helpful in patients with LV systolic dysfunction and for lowering the systolic blood pressure. This patient already has prerenal azotemia, and so it would be best to not simply deplete the intravascular volume even further with more diuretics. Positive inotropic agents like digoxin are effective in patients with CHF secondary to systolic dysfunction. Although they do not reduce mortality, these agents are effective in reducing rates of hospitalization and in improving symptoms. They are also useful when worsening heart failure is from atrial fibrillation with poor rate control.
Explanation:
This patient has congestive heart failure (CHF) due to diastolic dysfunction secondary to chronic hypertension, with no mention of left ventricular (LV) systolic dysfunction. Diastolic dysfunction is more common in elderly, hypertensive patients. Signs of pulmonary or venous congestion in patients with a LV chamber of normal size indicate diastolic dysfunction. The hypertrophic, stiff left ventricle needs more time to fill during diastole, so treatment with beta-blockers helps in slowing the heart rate and increasing cardiac output. Even though he has asthma, his is not wheezing now, and so it would be best to decrease his mortality with beta-blockers. Diuretics and nitrates should be used with caution because the decrease in preload may decrease cardiac output and cause hypotension. The use of increased diuretics is helpful in volume-overloaded patients for relief of severe edema, which is not present in this case. Reassurance, dietary modification alone, and rescheduling a return appointment is not an option in this symptomatic patient. ACE inhibitors are more helpful in patients with LV systolic dysfunction and for lowering the systolic blood pressure. This patient already has prerenal azotemia, and so it would be best to not simply deplete the intravascular volume even further with more diuretics. Positive inotropic agents like digoxin are effective in patients with CHF secondary to systolic dysfunction. Although they do not reduce mortality, these agents are effective in reducing rates of hospitalization and in improving symptoms. They are also useful when worsening heart failure is from atrial fibrillation with poor rate control.