A 65-year-old female who has heart failure with an ejection fraction of 35% is found to have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3 and T4 levels
... [Show More] are normal, and her thyroid gland is normal to palpation. You check her levels again in 2 months and they are unchanged. You advise her that
hypothyroidism decreases her metabolic rate, which reduces the stress on her heart
hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms
subclinical hypothyroidism has negative effects on heart failure and treatment should be considered
treatment of subclinical hypothyroidism would raise her LDL-cholesterol level
C
Clinical hypothyroidism has long been associated with cardiac dysfunction. It has also been shown that subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline low thyroid hormone levels) can cause left ventricular systolic and diastolic dysfunction, which improves with thyroid replacement therapy. Patients with overt or subclinical hypothyroidism should be treated with levothyroxine to improve their cardiovascular function and decrease the potential risk of heart failure. Thyroxine in excess can exacerbate coronary artery disease, and should be started at low doses and increased slowly in patients with possible underlying coronary artery disease. Results of meta-analyses indicate that therapy will lower, not raise, serum LDL-cholesterol levels.
A 58-year-old male is hospitalized with severe decompensated heart failure refractory to intravenous inotropic therapy and guideline-directed medical therapy. You are considering referral to a tertiary care hospital for mechanical circulatory support to bridge to transplantation.Which one of the following is true regarding mechanical circulatory support bridge therapy?
It should be limited to patients who meet the criteria for heart transplantation
It should only be used in patients with biventricular heart failure
It generally improves quality of life while waiting for transplantation
It greatly reduces quality of life while waiting for transplantation
c
Mechanical circulatory support (MCS) with a ventricular assist device has continued to evolve and has emerged as a viable therapeutic option for patients with advanced stage D heart failure with reduced ejection fraction refractory to guideline-directed medical therapy and cardiac device intervention. A variety of ventricular assist devices are now available. These devices may be either intracorporeal or extracorporeal, and may be designed to assist the left ventricle, right ventricle, or both.Bridge therapy refers to the use of left ventricular assist devices to help a patient survive until a donor heart becomes available for transplantation. Several devices are available, some of which are implantable and allow patients to be discharged to their homes. These devices can increase patient activity levels and quality of life. Complications can occur, including stroke, infection, and death, but these devices can be lifesaving in patients with refractory heart failure.The data from the Interagency Registry for Mechanically Assisted Circulatory Support indicates that cardiogenic shock, advanced age, and severe right heart failure (manifested as ascites or increased bilirubin) are major risk factors for death after MCS. This led to a recommendation that referral for MCS be considered before severe right ventricular failure develops. Possible indications for a bridge-to-candidacy ventricular assist device include obesity, tobacco use, and severe pulmonary hypertension in patients who might otherwise be candidates for transplantation.
An active 66-year-old female presents with intermittent chest pain and dyspnea. She is currently pain free. A resting EKG is normal.If found on the history and examination, which one of the following symptoms is most likely to be associated with myocardial ischemia as the cause of chest pain?
An episode of diaphoresis associated with the chest pain
Pain reproduced by chest wall palpation on the left side of the chest
Pain that comes and goes with and without exertion
Intermittent pleuritic-type pain and dyspnea
A
Cardiac ischemia is classically defined as deep, poorly localized chest or arm discomfort reproducibly associated with exertion or emotional stress. It is relieved with rest and nitroglycerin. It can present in an atypical fashion, and the discomfort can localize or radiate to the neck, lower jaw, throat, shoulder, epigastrium, hands, or upper back. It may be entirely absent in some cases. In older patients without chest pain, new-onset or unexplained exertional dyspnea is the most common anginal equivalent, even with a normal resting EKG.Although they may be present, pleuritic-type pain, pain reproduced with movement or palpation of the chest wall or arm, and sharp or stabbing pain are not characteristic features of myocardial ischemia. Very brief episodes of pain, lasting a few seconds or less, are also not characteristic of myocardial ischemia. In a meta-analysis of symptoms useful in diagnosing acute coronary syndrome in a low-risk setting, diaphoresis was found to be the strongest predictor of myocardial infarction (MI) (likelihood ratio [LR] = 2.44), and the presence of chest wall tenderness significantly reduced the possibility of MI (LR = 0.23). A completely normal EKG does not exclude the possibility of acute coronary syndrome because 1%-6% of such patients eventually are found to have an acute myocardial infarction (non-ST-segment elevation by definition) and at least 4% have unstable angina.
A 69-year-old female with a history of chronic hypertension and a previous myocardial infarction sees you for follow-up 6 weeks after being hospitalized for chest pain. During her hospitalization she underwent cardiac catheterization, which showed only a lesion in the circumflex that was less than 50% occluded. An EKG revealed sinus bradycardia of 52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography revealed a left ventricular ejection fraction of 32%.Although the patient feels comfortable at rest she reports that she has difficulty walking up a single flight of stairs. Her current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 40 mg daily; and aspirin, 81 mg daily.On examination the patient is not in acute distress. Her blood pressure is 132/78 mm Hg and her pulse rate is 55 beats/min. A lung examination reveals bibasilar rales. Auscultation of the heart reveals a regular rhythm with a soft S3 and S4 and no murmur.Which one of the following interventions has been shown to improve survival in patients such as this?
Increasing the furosemide dosage
Adding amlodipine (Norvasc)
Adding digoxin
Adding eplerenone (Inspra)
Cardiac resynchronization therapy
D
Aldosterone antagonists are important in the management of severe heart failure. The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the EMPHASIS-HF trial (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial) found that the addition of eplerenone in heart failure patients with mild symptoms consistent with New York Heart Association (NYHA) class II heart failure and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current American Heart Association guidelines recommend the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF.Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B). According to recent guidelines, patients are considered candidates for cardiac resynchronization therapy if they have NYHA class II-IV heart failure, a left ventricular ejection fraction ≤35%, and a QRS duration >130 ms on an EKG. However, 30%-35% of patients who meet these criteria are nonresponders with no symptomatic improvement or reverse left ventricular remodeling. Left bundle branch block morphology, a QRS duration ≥150 ms, and adequate coronary sinus anatomy have been most closely associated with a favorable response. Mitral valve regurgitation, right ventricular dysfunction, and atrial fibrillation have been shown to have a negative impact on patient response. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided.
You admit a patient with acute coronary syndrome to the hospital. Which one of the following is true regarding the differences between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) in this situation?
The use of glycoprotein IIb/IIIa inhibitors does not require a change in the dosage of UFH
The dosage of both should be titrated to achieve a partial thromboplastin time of 1.5-2.5 times control
Platelet activation is the same for both
The incidence of thrombocytopenia is lower with LMWH
UFH has higher bioavailability because it is given intravenously
D
Anticoagulation is recommended in addition to antiplatelet therapy for all patients with acute coronary syndrome regardless of the initial treatment strategy. For patients managed with an early invasive strategy, heparin exerts its anticoagulant effect by accelerating the action of circulating antithrombin. It is available as either intravenous unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH).LMWH offers greater bioavailability than UFH because of decreased binding to plasma proteins and endothelial cells, and it results in less platelet activation. The incidence of thrombocytopenia in patients treated with LMWH is less than with UFH. LMWH does not change the partial thromboplastin time (PTT) appreciably, so PTT should not be used to monitor the dosage. LMWH is a viable option for treatment of acute coronary artery syndrome and is preferred in many situations.If UFH is used it should be given intravenously at a dosage of 85 U/kg unless a glycoprotein IIb/IIIa inhibitor is also administered, in which case the dosage should be reduced to 60 U/kg. Dosing adjustments should be based on the target activated clotting time. Patients treated with UFH should be monitored by factor Xa assays.
An 82-year-old female presents with increasing dyspnea. Her husband is worried because she occasionally stops breathing when she is asleep. You have been treating the patient for heart failure for the past 2 years with ACE inhibitors, β-blockers, diuretics, and low-dose spironolactone (Aldactone). The nurse who measures the patient's blood pressure notes that the systolic sounds are heard first at a pressure of 135 mm Hg and a pulse rate of 40 beats/min. At 120 mm Hg the nurse hears Korotkoff sounds at a regular rate of 80/min.Which one of the following is true regarding this patient?
The examination findings are normal for patients in this age group
The patient's breathing pattern is normal for patients in this age group
Both the breathing and blood pressure findings may improve with more intensive treatment
Medications should be reduced in this patient because her blood pressure is unstable
C
This patient has pulsus alternans, which is common in patients with decompensated heart failure and advanced myocardial disease. Effective treatment can make this finding disappear. Cheyne-Stokes breathing is also common in patients with decompensated heart failure. If the heart failure is treated, the breathing abnormality can disappear. The patient has symptomatic heart failure, which classifies her heart failure as stage C at least, according to the American College of Cardiology/American Heart Association heart failure guidelines.
A 69-year-old female presents to the emergency department with a 1-hour episode of severe substernal chest pain that has now resolved. Her past medical history is notable for current tobacco abuse, hypertension, and depression. Her current medications include lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; citalopram (Celexa), 20 mg daily; and aspirin, 81 mg daily. On examination she has a blood pressure of 150/92 mm Hg and a pulse rate of 92 beats/min. An EKG reveals a sinus rhythm with deep and symmetrical T-wave inversions in the inferior leads.You decide to admit the patient to the hospital. Which one of the following should be administered on admission?
Alteplase (Activase) intravenously
Aspirin, 81 mg, and nitroglycerin via intravenous drip
Enoxaparin (Lovenox), 1 mg/kg subcutaneously, and nitroglycerin, 0.4 mg sublingually
Ticagrelor (Brilinta), 60 mg orally, and enoxaparin, 1 mg/kg subcutaneously
Ticagrelor, 180 mg, and aspirin, 325 mg
E
The management of unstable angina or non-ST-elevation myocardial infarction (NSTEMI) is similar to the management of ST-elevation myocardial infarction except that fibrinolytic therapy has no role in unstable angina or NSTEMI (SOR A). Studies indicate that fibrinolytic therapy in these patients has no benefit in terms of mortality or myocardial infarction (MI), and may even increase the risk for intracranial hemorrhage and both fatal and nonfatal MI.Unless there is a contraindication, all patients with acute coronary syndrome should begin dual antiplatelet therapy with aspirin, starting with a loading dose of 325 mg followed by a maintenance dosage of 81 mg daily, and a P2Y12 inhibitor (either clopidogrel, prasugrel, or ticagrelor), as well as anticoagulation therapy with either low molecular weight heparin (SOR A), fondaparinux in combination with a factor IIa inhibitor (SOR B), unfractionated heparin (SOR B), or bivalirudin in patients managed with an early invasive strategy (SOR B). β-Blockers have been shown to reduce myocardial ischemia, reinfarction, and the frequency of complex ventricular dysrhythmias, and they increase long-term survival. Provided there are no contraindications, American Heart Association guidelines recommend that oral β-blocker therapy be initiated within the first 24 hours in patients with acute coronary syndrome (SOR A).
In the United States, silent myocardial infarction is more common in which one of the following population groups?
Women more than men
Men more than women
Hispanics more than non-Hispanic whites
Non-Hispanic whites more than Asian-Americans
B
There is no evidence that silent myocardial infarction (MI), as detected by the Minnesota code, is more common in women than in men in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial cohort. Men were found to have a higher prevalence of silent MI on baseline EKGs than women (6% versus 4%, P = 0.001). Women had lower odds of silent MI than men after adjusting for other risk factors (odds ratio = 0.80, P = 0.04). Race and ethnicity were significantly associated with silent MI (P = 0.02), with Asian-Americans having the highest incidence and African-Americans and Hispanics having a lower incidence than non-Hispanic whites.
A 78-year-old male with chronic hypertension presents with a sudden onset of severe chest pain radiating to the back, associated with dyspnea and near-syncope. Which one of the following would suggest a diagnosis other than acute myocardial infarction?
A 3/6 holosystolic apical murmur and diffuse ST-segment elevation
A 2/6 diastolic murmur and weak radial and femoral pulses
Diffuse ST-segment elevation of 1-2 mm
A pulsus paradoxus of 10 mm Hg
Chest and back pain that was mild initially and increased over the next 2 hours
B
The chest pain of aortic dissection is typically described as searing, ripping, or tearing, and frequently radiates to the back or lower extremities. The pain is worst at the time of onset and lasts for hours. Helpful findings on physical examination include asymmetry of pulses or blood pressure, as well as a new murmur of aortic regurgitation (a decrescendo early diastolic murmur heard best in the aortic area, as opposed to holosystolic murmurs). This type of murmur indicates a dissection involving the ascending aorta. The dissection can extend to the pericardial sac and produce a pericardial friction rub on examination, as well as findings of cardiac tamponade. Pulsus paradoxus is a common finding of cardiac tamponade and is defined by a decrease in blood pressure of at least 12 mm Hg with inspiration.Aortic dissection is not usually associated with acute ischemic electrocardiographic changes. Data from the International Registry of Aortic Dissection indicates that ischemic changes were present on an EKG in only 15% of cases. The diagnosis can be established with transesophageal echocardiography, CT, or MRI. The importance of early diagnosis in a patient being evaluated for myocardial infarction is underscored by the fact that aortic dissection is exacerbated by fibrinolytic therapy and anticoagulation.Acute aortic dissection has a lethality rate of 1%-2% per hour after the onset of symptoms in untreated patients. Prompt diagnosis is therefore vital to increase the patient's chances of survival and prevent serious complications. Advanced age, male sex, a long-term history of arterial hypertension, and the presence of an aortic aneurysm confer the greatest population-attributable risk. However, patients with genetic connective tissue disorders such as Marfan, Loeys-Dietz, or Ehlers-Danlos syndrome, and patients with bicuspid aortic valves are at increased risk of aortic dissection at a much younger age.
A 62-year-old male comes to your office for a routine health maintenance evaluation. He has a history of hypertension, type 2 diabetes, and New York Heart Association class II heart failure. His current medications include metformin (Glucophage), 500 mg twice daily; benazepril (Lotensin), 40 mg daily; chlorthalidone, 12.5 mg daily; atorvastatin (Lipitor), 10 mg daily; and aspirin, 81 mg daily. A physical examination is notable only for a BMI of 29 kg/m2 and a blood pressure of 135/80 mm Hg. His hemoglobin A1c is 6.9%.Which one of the following additional medications would be appropriate to help manage his heart failure?
Amlodipine (Norvasc)
Digoxin
Losartan (Cozaar)
Metoprolol succinate (Toprol-XL)
Metoprolol tartrate (Lopressor)
D
Current American Heart Association guidelines recommend that a β-blocker, specifically either carvedilol, bisoprolol, or metoprolol succinate, be prescribed to all patients with stable heart failure with a reduced left ventricular ejection fraction. These three β-blockers have all been shown to prolong survival in patients with current or prior symptoms of heart failure. A class effect cannot be assumed. Studies have shown short-acting metoprolol tartrate to be less effective than sustained-release metoprolol succinate in reducing the risk of death in patients with chronic heart failure. Losartan should not be added to an ACE inhibitor. Amlodipine adds no benefit for heart failure. Digoxin would not be indicated in this patient since there is no history of atrial fibrillation or other tachyarrhythmia.
You see a 63-year-old female for follow-up 2 months after coronary artery bypass graft (CABG) surgery. In addition to clopidogrel or a similar antiplatelet medication, which one of the following should you recommend to reduce the repeat revascularization rate following CABG surgery?
Aspirin and β-blockers
Aspirin and statin therapy
β-Blockers and statin therapy
Postmenopausal hormone therapy and statin therapy
B
Aspirin has been shown to significantly reduce vein graft closures through the first postoperative year. According to current guidelines it should be continued indefinitely, given its benefit in preventing subsequent clinical events. After off-pump coronary artery bypass graft (CABG) surgery, dual antiplatelet therapy should be administered for 1 year using a combination of aspirin, 81-162 mg daily, and clopidogrel, 75 mg daily, to reduce graft occlusion. Aggressive statin therapy following CABG has been shown to result in less disease progression in saphenous vein grafts and to reduce the repeat revascularization rate. The American Heart Association recommends high-intensity statin therapy (atorvastatin, 40-80 mg daily, or rosuvastatin, 20-40 mg daily) after surgery for all CABG patients <75 years of age and moderate-intensity statin therapy for patients intolerant of high-intensity statin therapy and those >75 years of age. Hormone therapy and β-blockers have not been shown to affect the revascularization rate. Postmenopausal hormone therapy (estrogen/progesterone) should not be given to women undergoing CABG (SOR B).
A 68-year-old male with New York Heart Association class III heart failure with reduced ejection fraction and a blood pressure of 110/70 mm Hg is currently taking furosemide (Lasix), 40 mg twice daily, and carvedilol (Coreg), 12.5 mg twice daily. Which one of the following changes to this patient's current regimen will reduce his mortality risk and risk of future hospitalization for heart failure?
Increasing the dosage of furosemide
Adding digoxin
Adding lisinopril (Prinivil, Zestril)
Adding metolazone
C
ACE inhibitors such as lisinopril have been shown to decrease both mortality and rehospitalizations for heart failure, and are the mainstay of treatment for patients who can take them. Digoxin improves symptoms and exercise tolerance but does not decrease mortality. There have been no long-term studies conducted to determine the effects of diuretics such as furosemide and metolazone on morbidity and mortality.
A 29-year-old male is evaluated in the emergency department for chest pain that started after he used cocaine, and which has now resolved. An EKG shows a prolonged QTc interval, new T-wave inversions, and biphasic T waves in leads V2 and V3. The physical examination reveals an anxious male with a blood pressure of 160/100 mm Hg and a heart rate of 118 beats/min.Which one of the following is true in this situation?
The initial treatment should include aspirin and clopidogrel
β-Blockers should never be used in patients with cocaine-related chest pain
The treatment of choice is intravenous benzodiazepines and oral or intravenous nitrate therapy
Nifedipine (Procardia) should be used as first-line therapy if the patient's blood pressure is elevated
C
Myocardial infarction has been found in 6% of patients presenting to the emergency department with cocaine-associated chest pain. Cocaine precipitates coronary artery spasm by stimulating α-adrenergic receptors in smooth muscle cells in coronary arteries, as well as by increasing levels of endothelin-1 and reducing production of nitric oxide. Cocaine has also been found to increase the response of platelets to arachidonic acid, thus increasing thromboxane A2 production and platelet aggregation, and to lead to accelerated atherosclerosis in chronic users. Increased motor activity, along with skeletal muscle injury and rhabdomyolysis, is also associated with cocaine use, causing creatine kinase and even CK-MB elevation in the absence of myocardial infarction. As a result, cardiac troponin I or T is preferred for detecting myocardial necrosis.In most cases the initial management of cocaine-associated chest pain should include nitrate therapy and a benzodiazepine. Benzodiazepines relieve cocaine-associated chest pain and also reduce anxiety and the central stimulatory effects of the cocaine, indirectly improving hypertension and tachycardia. Nitrate therapy has been shown to reduce cocaine-associated chest pain, reverse cocaine-associated vasoconstriction, and lower blood pressure. Nifedipine is not recommended as first-line treatment but other calcium channel blockers such as diltiazem may be used for blood pressure control. It was previously thought that β-blockers were harmful in patients with chest pain associated with cocaine ingestion but that has been disproven in many recent studies. Labetalol and metoprolol are both safe and may have a beneficial effect in this situation.This patient's EKG is characteristic of Wellens syndrome, or left anterior descending coronary artery (LAD) T-wave syndrome. These EKG changes indicate post-ischemic reperfusion injury, typically related to critical narrowing of the LAD. Cocaine users may have EKG changes typical of Wellens syndrome as part of a vasospastic phenomenon without underlying stenosis.
A 61-year-old male sees you for a follow-up visit. His medical history includes end-stage heart failure, chronic atrial fibrillation, a left ventricular ejection fraction of 30%, and stage 4 chronic kidney disease. He is taking optimal dosages of lisinopril (Prinivil, Zestril), metoprolol succinate (Toprol-XL), furosemide (Lasix), digoxin, and spironolactone (Aldactone). He continues to have symptoms of heart failure with minimal exertion, but not at rest. An EKG shows a ventricular rate of 85 beats/min, a QRS duration of 0.14 sec, and old Q waves in the inferior leads.Appropriate management options for this patient include which one of the following?
Adding a nondihydropyridine calcium channel blocker
Adding a thiazide diuretic
Switching from metoprolol succinate to metoprolol tartrate (Lopressor)
Synchronized biventricular pacing
D
Biventricular pacing with an implantable defibrillator can improve symptoms and increase survival in heart failure patients with a prolonged QRS duration, and is recommended for those with a low ejection fraction, given their increased risk for ventricular fibrillation.Patients with refractory heart failure on optimal medical therapy should be considered for a heart transplant. Patients with an anticipated 1-year survival probability <50% can benefit from left ventricular (LV) assist devices. Patients who have a narrow QRS and stage D heart failure despite optimal medical therapy, and who are not candidates for transplant or LV assist devices, should not receive a defibrillator if their expected survival related to heart failure or other comorbidities is less than 1-2 years, since a defibrillator will not improve their survival.Changing from metoprolol succinate to metoprolol tartrate will not be beneficial since the succinate form is the preferred formulation for heart failure. Nondihydropyridine calcium channel blockers reduce the ejection fraction and would therefore not be beneficial in this patient. Patients with severe heart failure and severe chronic kidney disease generally do not respond favorably to thiazide diuretics.
You see a 58-year-old male for a routine examination. According to the American College of Cardiology/American Heart Association classification system, which one of the following would meet the criteria for stage B heart failure, assuming he has no additional complications?
A history of dyspnea on exertion
Well compensated heart failure
A grade 2/6 apical holosystolic murmur radiating to the axilla
Uncontrolled type 2 diabetes
C
A significant heart murmur, such as a grade 2/6 apical holosystolic murmur that radiates to the axilla, is generally meaningful. The American College of Cardiology/American Heart Association classification of heart failure includes four stages. Stage A is defined as the absence of structural disease in a patient at high risk for the development of heart failure. This includes patients with hypertension, atherosclerotic disease, diabetes mellitus, obesity, metabolic syndrome, or a family history of cardiomyopathy, as well as those using cardiotoxins. Patients with stage B heart failure have evidence of structural heart disease, such as a previous myocardial infarction, asymptomatic valvular disease, or evidence of left ventricular remodeling such as left ventricular hypertrophy or a low ejection fraction. Any patient with structural heart disease is at risk of heart failure and should be managed aggressively to prevent complications in the future.Stage C is defined as structural heart disease with prior or current symptoms of heart failure. Patients with stage D heart failure have refractory heart failure requiring specialized interventions.
A 61-year-old male sees you for a routine annual evaluation. A review of systems is notable only for nocturia 1-2 times per night. He has a history of a non-ST-elevation myocardial infarction 2 years ago treated with a drug-eluting stent. His current medications are metoprolol tartrate (Lopressor), 50 mg twice daily; hydrochlorothiazide, 25 mg daily; atorvastatin (Lipitor), 40 mg daily; aspirin, 81 mg daily; and docusate as needed. He is a nonsmoker. His blood pressure is 132/82 mm Hg. A physical examination is normal.Which one of the following medications is indicated at this time?
Diltiazem (Cardizem)
Enalapril (Vasotec)
Furosemide (Lasix)
Losartan (Cozaar)
Spironolactone (Aldactone)
B
Despite the absence of symptoms and a left ventricular ejection fraction within the normal range, this patient's previous myocardial infarction (MI) is evidence of structural heart disease, making his American College of Cardiology/American Heart Association (ACC/AHA) heart failure classification stage B. Patients without heart failure symptoms who have had an MI or who have evidence of left ventricular remodeling are thought to be at considerable risk of developing heart failure and intervention is warranted. Patients who are at risk of future heart failure should take an ACE inhibitor if they can tolerate it.In addition to optimal management of hyperlipidemia and hypertension, the AHA recommends that ACE inhibitors and β-blockers such as carvedilol, metoprolol succinate, or bisoprolol be used in all patients with a recent or remote history of MI, regardless of ejection fraction or the presence of heart failure (SOR A). Two large-scale studies have demonstrated that prolonged therapy with an ACE inhibitor reduces the risk of a major cardiovascular event even when treatment is initiated months or years after the MI.Furosemide is not recommended for use in stage B patients, and calcium channel blockers such as diltiazem can lead to worsening heart failure and should be avoided. The AHA recommends that angiotensin receptor blockers be administered to post-MI patients without heart failure who are intolerant of ACE inhibitors and have a low left ventricular ejection fraction (SOR B). Aldosterone antagonists would not be the first-line therapy for stage B heart failure.
A 74-year-old female is discharged from the hospital after being treated for an exacerbation of heart failure with volume overload. She has a previous history of coronary heart disease and hypertension. Her discharge medications include furosemide (Lasix), 20 mg twice daily; lovastatin, 40 mg daily; ramipril (Altace), 5 mg daily; spironolactone (Aldactone), 12.5 mg twice daily; metoprolol succinate (Toprol-XL), 75 mg daily; and aspirin, 81 mg daily. In addition, she is instructed to avoid the use of ibuprofen and other NSAIDs and to add metolazone, 2.5 mg daily, with 30 mL of 10% potassium chloride elixir on mornings when her weight is more than 3 lb over her target weight of 130 lb.Which one of the following is the most common reason for medication nonadherence in patients such as this?
Cost
Concerns regarding potential side effects
Conflicting instructions from different health care providers
Failure to understand discharge instructions
Doubts about the need for the medications
D
Medication compliance and understanding of how and why to take medications is a crucial aspect of medical care in heart failure. A study of patients recently discharged from the hospital following an exacerbation of heart failure found a high rate of medication nonadherence, with only one-third of patients taking all their medications as prescribed and not taking unprescribed medications. Of those not taking medications as prescribed, the most common reason given was not understanding discharge instructions (57%). Less common reasons include confusion due to conflicting instructions from the discharging physician and the primary care physician, medication cost, being unconvinced of the utility of the medication, and concerns regarding potential side effects (SOR B). [Show Less]