A 71-year-old man comes to the physician for routine evaluation. He has no symptoms and considers himself healthy. He walks several miles a day and jogs twice a week for 5 miles. The patient has no history of chest pain or syncope. Five years ago he had inguinal hernia repair without complications. His father died at age 90 of "old age" and his mother died of breast cancer. He has never smoked.
His blood pressure is 126/70 mm Hg and pulse is 72/min and regular. He has no jugular venous distension when sitting. The apical impulse is displaced to the left. A 2/6 holosystolic murmur is heard at the apex. The lungs are clear, and there is no organomegaly. The pulses are full bilaterally and there is no peripheral edema. ECG shows normal sinus rhythm with abnormal Q waves in leads V2 to V4. Transthoracic echocardiography shows left ventricular enlargement, anterior wall and apical akinesis, and left ventricular ejection fraction of 35%. There is mild mitral regurgitation. He declines coronary angiogram.
Which of the following is the best next step in management of this patient?

Question

A 71-year-old man comes to the physician for routine evaluation.  He has no symptoms and considers himself healthy.  He walks several miles a day and jogs twice a week for 5 miles.  The patient has no history of chest pain or syncope.  Five years ago he had inguinal hernia repair without complications.  His father died at age 90 of "old age" and his mother died of breast cancer.  He has never smoked.
His blood pressure is 126/70 mm Hg and pulse is 72/min and regular.  He has no jugular venous distension when sitting.  The apical impulse is displaced to the left.  A 2/6 holosystolic murmur is heard at the apex.  The lungs are clear, and there is no organomegaly.  The pulses are full bilaterally and there is no peripheral edema.  ECG shows normal sinus rhythm with abnormal Q waves in leads V2 to V4.  Transthoracic echocardiography shows left ventricular enlargement, anterior wall and apical akinesis, and left ventricular ejection fraction of 35%.  There is mild mitral regurgitation.  He declines coronary angiogram.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9750_e014_853d_41a850551a69_MD0002_00 This patient has asymptomatic left ventricular (LV) systolic dysfunction. Such patients are typically identified via echocardiography performed due to an abnormal physical examination or ECG finding, and meet criteria for New York Heart Association (NYHA) class I heart failure. class I In patients with asymptomatic LV systolic dysfunction and an ejection fraction ≤40%, angiotensin system blockade has been shown to delay the onset of symptomatic heart failure, reduce adverse cardiac events, and improve mortality. Therefore, all such patients should be initiated on an angiotensin system inhibitor (eg, ACE inhibitor) (Choice D). In addition, patients with asymptomatic LV systolic dysfunction should also be started on a beta blocker (eg, metoprolol) due to evidence of similar improvements in cardiac morbidity and mortality. This recommendation is strongest in those with a history of myocardial infarction, which is likely the case in this patient with anterior Q waves on ECG. (Choice B) Loop diuretics (eg, furosemide) are indicated in patients with symptomatic heart failure (ie, NYHA II, III, and IV) and evidence of volume overload, but are not indicated in asymptomatic patients. (Choice C) Digoxin can improve symptoms and reduce the rate of repeat hospitalization in patients with symptomatic systolic heart failure, but it has not been shown to benefit patients with asymptomatic LV systolic dysfunction. (Choice E) Strict dietary salt restriction (eg, <2 g per day) has been shown to worsen outcomes in patients with heart failure, possibly due to enhancement of renin-angiotensin-aldosterone system activity. Moderate dietary salt intake of approximately 3 g per day is a more suitable target in patients with volume overload; a higher target may be appropriate in asymptomatic heart failure patients. Educational objective: The initiation of an angiotensin system inhibitor is indicated in patients with asymptomatic left ventricular systolic dysfunction with an ejection fraction ≤40%, as the therapy has been shown to delay the onset of symptoms and improve survival. Patients with asymptomatic left ventricular systolic dysfunction should be initiated on a beta blocker as well; this recommendation is strongest in those with a recent myocardial infarction. __________ References: Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. (http://www.ncbi.nlm.nih.gov/pubmed/1463530) Metoprolol reverses left ventricular remodeling in patients with asymptomatic systolic dysfunction: the REversal of VEntricular Remodeling with Toprol-XL (REVERT) trial. (http://www.ncbi.nlm.nih.gov/pubmed/17576868) 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee (http://www.ncbi.nlm.nih.gov/pubmed/33446410)

A 71-Year-Old Man Comes to the Physician for Routine Evaluation