Medicine>>>>>Hospital-Based Medicine
Question 7#

You are caring for a 72-year-old man admitted to the hospital with an exacerbation of congestive heart failure. Two weeks prior to admission, he was able to ambulate two blocks before stopping because of dyspnea. He has now returned to baseline and is ready for discharge. His preadmission medications include aspirin, metoprolol, and furosemide. Systolic blood pressure has ranged from 110 to128 mm Hg over the course of his hospitalization. Heart rate was in 120s at the time of presentation, but has been consistently around 70/minute over the past 24 hours. An echocardiogram performed during this hospitalization revealed global hypokinesis with an ejection fraction of 30%. Which of the following medications, when added to his preadmission regimen, would be most likely to decrease his risk of subsequent mortality?

a. Digoxin
b. Enalapril
c. Hydrochlorothiazide
d. Propranolol
e. Spironolactone

Correct Answer is B


Inhibition of the renin-angiotensin-aldosterone system by either angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) has been proven to decrease mortality in patients with symptoms of congestive heart failure and a depressed ejection fraction. All patients with a history of congestive heart failure should be maintained on a beta-blocker and an ACEi or ARB. Most patients will require a diuretic for symptom control. Digitalis glyco-sides decrease rehospitalization rate but have not been shown to improve mortality. Thiazide diuretics are excellent medications for blood pressure control. Our patient, however, has well-controlled blood pressure. The patient is already on a selective beta-blocker and the addition of a non-selective beta-blocker is unlikely to be helpful. Spironolactone provides mortality benefit in patients with NYHA class III or IV heart failure. The patient in this scenario was able to walk two blocks before stopping and would be classified as NYHA class II.