A 31-year-old woman with hypertrophic cardiomyopathy presents to your office for follow-up. She has been doing well. She denies any palpitation or syncope. She has researched her disease on the Web and found out that most people die of arrhythmia. She would like to have an EP study.
Which of the following is the predictive value of the EP study for ventricular arrhythmia?
20%. There is no role for routine EP study in the asymptomatic hypertrophic cardiomyopathy patient.
A 61-year-old woman with an EF of 50% is admitted with an AFib with rapid ventricular response. She is started on metoprolol tartrate with excellent rate control and heparin. Her daughter, who is a nurse, wants to know why you did not start her on dofetilide because this is the best new drug.
What is your response?
Dofetilide was used in patients with an EF less than 35%. The study compared dofetilide with amiodarone. Dofetilide did not increase mortality. It has not been studied against β-blockers or calcium channel blockers in patients with normal EF.
A 79-year-old woman with HTN and non-insulin-dependent diabetes mellitus comes to your office for a second opinion. She is doing well and is currently on enalapril, aspirin, simvastatin, glipizide, and metformin. She read in her monthly American Association of Retired Persons newsletter that losartan is better than enalapril. She wants you to change her prescription. Based on trial data, which of the following is your recommendation?
Losartan showed neither mortality benefit nor reduced hospitalization. In the large Evaluation of Losartan in the Elderly II study, losartan did not show mortality benefit or reduced hospitalization. Losartan was better tolerated than captopril. Because the patient has no side effects with enalapril, her prescription should not be changed.
A 61-year-old woman with CHF and an EF of 25% is admitted with CHF exacerbation to your partner’s service. On the day of discharge, your partner is sick, and you must explain her discharge medications. You explain to her the benefits of lisinopril, simvastatin, aspirin, digoxin, and furosemide. Finally, you want to explain the benefit of spironolactone (Aldactone) to her.
What is your explanation?
Spironolactone in addition to standard therapy decreases mortality and rehospitalization. In the Randomized Aldactone Evaluation Study, patients with NYHA class III or IV with an EF less than 35% had improvement in mortality, reduction in hospitalization, and improvement in functional class when spironolactone was taken in addition to standard therapy (ACE inhibitor and diuretic).
A 63-year-old man with non-insulin-dependent diabetes mellitus, HTN, hyperlipidemia, and chronic renal insufficiency is admitted with acute anterior wall MI 10 hours after symptom onset. He is taken emergently to the cardiac catheterization laboratory. He is noted to have proximal LAD occlusion, and he undergoes a successful PTCA/stent to the LAD with abciximab and heparin. His EF is noted to be 30% on a TTE performed 3 days later. On hospital day 4, he reports chest pain and is found to be in AFib with an HR of 121. His BP is 90/44 mmHg, and he is short of breath and anxious.
Which of the following should you administer next?
Cardioversion. This patient has post-MI AFib. He has LV dysfunction and renal insufficiency. Procainamide should be used in patients with normal LV and renal clearance. Amiodarone would take too long to work, and he is already in distress. Lidocaine is not used in AFib. Metoprolol tartrate would exacerbate his heart failure; therefore, cardioversion is the only choice.
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