A 62 year-year-old man comes to you with progressive easy tiredness, moderate exertional breathlesness and orthopnea of a one year duration.
On Examination BP 110/60 mm Hg, pulse 100/minutes and unlabored repirations at 22/min. Neck veins are engorged three cms above the clavicle at 30 degrees and the abdomino-jugular reflux is positive. The apical impulse is located 2 cms lateral to the left mid-clavicular line in the sixth interspace. Soft S3 and S4 gallops together with a grade 2/6 holosytolic murmur are heard at the apex. There are bibasilar inspiratory rales and pitting edema of the legs.
Chest x-ray PA view reveals moderate cardiomegaly with pulmonary congestion. ECG reveals a sinus mechanism with a left bundle branch block and frequent unifocal PVCs. Echocardiography reveals a left ventricular end-diastolic dimension of 60 mm with global hypokinesia, EF of 38%-40% and moderate Mitral Regurgitation. The IVC is moderately distended and demonstrates poor inspiratory collapse.
Which Drug Should be used first in the management of this Patient?
On Examination BP 110/60 mm Hg, pulse 100/minutes and unlabored repirations at 22/min. Neck veins are engorged three cms above the clavicle at 30 degrees and the abdomino-jugular reflux is positive. The apical impulse is located 2 cms lateral to the left mid-clavicular line in the sixth interspace. Soft S3 and S4 gallops together with a grade 2/6 holosytolic murmur are heard at the apex. There are bibasilar inspiratory rales and pitting edema of the legs.
Chest x-ray PA view reveals moderate cardiomegaly with pulmonary congestion. ECG reveals a sinus mechanism with a left bundle branch block and frequent unifocal PVCs. Echocardiography reveals a left ventricular end-diastolic dimension of 60 mm with global hypokinesia, EF of 38%-40% and moderate Mitral Regurgitation. The IVC is moderately distended and demonstrates poor inspiratory collapse.
Which Drug Should be used first in the management of this Patient?
- Digoxin
- Ramipril
- Amiodarone
- Metoprolol
Please Leave your comments and explanations in the box below
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Tough call. Sounds like patient has HF with moderate mitral regurg (of uncertain etiology) - so cautious ACE-inhibitor therapy (RAMIPRIL) would seem first step, with careful attention that his already low BP (110/60) isn't adversely affected - but afterload reduction may help medically with his mitral regurg.
ReplyDeleteI am agree with u, Ramipril can be given followed by a diuretic.
ReplyDeleteagree with ramipril, but this patient once his acute situation is optimized is headed for MVR versus replacement provided his LHC does not show any significant CAD, often MR patient do not become symptomatic till their EF drops significantly,,,,because of significant volume overload on the ventricle. By the time one thinks of valve repair or replacement it may be too late.
ReplyDeleteRamipril is the first drug to be given together with lasix
ReplyDeleteDr.Amal Talaat Eissa
I think the first drug should be IV diuretics in this acute decompensated heart failure, because this should be symptomatic therapy and faster in controlling the patient's symptoms. I do not agree with the valve repair or replacement as I do not think this is the primary cause of his heart disease. I will approach this patient as follow: 1. I will do a SPECT scan for this patient to R/O ischemia, despite the echo does not suggest so. 2. I will do a 48 hours Holter monitor to estimate the burden of the PVCs and to see if they are of the same or different morphologies. If the burden is > 10% and monomorphic, then there is a high probability that this is PVC-induced CMP. If it is negative and no other obvious cause then this can be idiopathic dialted CMP and I will start optimal medical therapy with ACEIs, Diuretics, BBs, Aldospirone antagonists and possible Statins and reassess in 3 months. If there is clinical response, then continue, if not then you need to refer him to an electrophysiologist for CRT.
ReplyDeleteI am also with I'V Diuretics
DeleteThnx for contribution
Patient with Bi Ventricular heart failure, low EF, I will go with the Ramipril.
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