Y. J. is a 67-year-old African American man with HF who has been treated with lisinopril 20 mg daily, metoprolol succinate 25 mg daily, furosemide 40 mg twice daily, and spironolactone 12.5 mg daily. Despite his current therapy, he still complains of shortness of breath while conducting usual daily activities. What is the most appropriate change that should be made to his regimen?
c. Initiate isosorbide dinitrate and hydralazine. The ACC/AHA guidelines recommend the initiation of isosorbide dinitrate and hydralazine as a reasonable addition to standard therapy in blacks with New York Heart Association class III/IV HF. The A-HeFT trial evaluated a proprietary drug combination (hydralazine 37.5 mg and isosorbide dinitrate 20 mg per tablet) in African Americans with HF along with standard treatment; because of significant mortality benefit, the study was prematurely discontinued.
Which of the following statements is true?
c. The benefit of long-term IV inotropic therapy may outweigh the increased mortality risk in refractory patients unable to be weaned from IV inotropic support. Because long-term IV positive inotropic therapy may cause an increased risk of death, such therapy is not regularly recommended. This risk, however, may be outweighed in patients who cannot be weaned from continuous support. Such patients with refractory HF may experience an improved quality of life because of the relative clinical stability afforded by the inotrope; therefore, IV positive inotropic therapy may be considered as a palliative measure in end-stage HF. The DIG (Digitalis Investigation Group) trial showed that digoxin’s benefit in HF was the alleviation of symptoms and improvement in clinical status. These findings were associated with a decreased morbidity (fewer hospitalizations) but not mortality. Because digoxin has negligible effect on survival, it is recommended that digoxin be used in conjunction with diuretics, ACE inhibitors, and β-blockers to decrease the clinical symptoms of HF. Furthermore, little evidence supports the practice of dosing digoxin according to serum levels. This is because of the lack of data exhibiting a relationship between digoxin serum concentrations and therapeutic effect. In the RALES trial, spironolactone was shown to be associated with reduced mortality and morbidity. However, the patients who were included in this trial were patients with class IV HF. Therefore, it would only be prudent to consider spironolactone in patients with recent or current severe HF symptoms. Efficacy and safety of spironolactone’s use in patients with mild-to-moderate HF is yet to be determined.
One month ago, a 37-year-old woman with sinus infection responded well to a 14-day course of amoxicillin/clavulanate 875/125 mg twice daily. She is scheduled for a root canal in 1 week. In the past, her dentist had prescribed one dose of clindamycin 600 mg, 1 hour prior to any dental work, for endocarditis prophylaxis because of her history of mitral valve prolapse. Realizing she has not received her prescription, the patient calls the dentist’s office for an antibiotic. What prophylaxis is indicated for this patient?
d. No prophylaxis is recommended in this patient. The recommendations according to the 2007 Guidelines for Prevention of Infective Endocarditis no longer recommend prophylactic antibiotics prior to dental procedures for people with mitral valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis, or congenital heart conditions such as ventricular septal defect, atrial septal defect, and hypertrophic cardiomyopathy.
S. C. is a 59-year-old woman diagnosed with enterococcal endocarditis. She has no known drug allergies. Which of the following would exhibit standard therapy?
b. Ampicillin, 2 g IV every 4 hours for 4 to 6 weeks, plus gentamicin, 1 mg/kg IV every 8 hours for 4 to 6 weeks. Treatment of enterococcal endocarditis is complicated because of the high levels of resistance to penicillin, extended-spectrum penicillins, and vancomycin. However, penicillin, ampicillin, or vancomycin in combination with an aminoglycoside causes synergistic bactericidal effect on these organisms. Treatment with an aminoglycoside for the full 4 to 6 weeks at a synergistic dose (1 mg/kg IV every 8 hours) in addition to the penicillin agent or vancomycin is required.
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