You are taking care of a 65-year-old man with history of coronary artery disease and prior bypass surgery. He is currently taking carvedilol and lisinopril at maximum doses. He was recently hospitalized for heart failure 3 months ago.
Which of the following criteria would make it reasonable to add eplerenone to his regimen?
EF of 20% and dyspnea while doing chores at home (New York Heart Association [NYHA] class II symptoms). Based on the results of EmphasisHF trial, patients with NYHA class II symptoms and EF <30% are eligible for adding eplerenone to their regimen if they were hospitalized in the last 6 months or had an elevated brain natriuretic peptide. This extended the patients who could be placed on an aldosterone blocker. Previous studies studied the benefit of spironolactone in patients with NYHA class IV symptoms in the last 6 months and EF ≤35% and eplerenone in patients 2 weeks post-MI with EF ≤40% and signs of heart failure. Aldosterone antagonists should not be used in patients with creatinine clearance <30 mL/min/1.73 m2 . EF or QRS alone are not enough to determine patients who would benefit. Functional class assessment is important.
For a patient with heart failure, coronary artery bypass grafting (CABG) is not reasonable for a patient with severe three-vessel coronary artery disease and:
No viability found on dobutamine echo with EF of 15%. The use of surgical revascularization of coronary disease and systolic heart failure is reasonable in patients with acute coronary syndrome and symptomatic angina. Although in the STITCH (Surgical Treatment for Ischemic Heart Failure) trial, a study of medical therapy versus CABG in patients with EF ≤35%, there was no difference in all-cause mortality, there was a suggestion of a trend toward patients with CABG having fewer hospitalizations for heart failure or death from cardiovascular causes. The choice of CABG in a patient with no viability and very low EF is unlikely to be successful in improving morbidity or mortality from heart failure.
A 60-year-old African American man comes to your clinic with few months’ history of fatigue, dyspnea on exertion, and lower extremity edema. He has no history of prior coronary artery disease or heart failure.
What features on an echo would not be consistent with amyloid heart disease?
Normal tissue Doppler measurement of the left ventricular (LV) lateral and septal walls. Patients with amyloid heart disease usually show restrictive pattern of diastology with low tissue Doppler of the LV myocardium.
Which of the following characterizes heart failure?
Downregulation primarily of β1 -receptors with little change in β2 - receptors. In the cardiac myocyte, there are 3 adrenergic receptors (α1 , β1 , and β2 ). In a normal heart the predominant β receptor is β1 . In a failing heart there is selective down-regulation of β1 receptors not β2 receptors.
In the Veterans Administration Heart Failure Trial II (V-HeFT II), which combination of medications improved LV function and exercise tolerance?
Hydralazine plus nitrates. In the V-HeFT II trial, although ACE inhibitors improved survival, it was hydralazine in combination with nitrates that had greater improvement in LV function and exercise tolerance.
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