A 68-year-old man comes to the office due to several weeks of progressive exertional dyspnea and lower extremity edema. Medical history is significant for non-Hodgkin lymphoma, which is in remission after chemotherapy 8 years ago. Blood pressure is 126/76 mm Hg and pulse is 88/min. Physical examination reveals bibasilar lung crackles and 1+ bilateral lower extremity edema. Echocardiography shows biventricular dilation and a left ventricular ejection fraction of 35%. Stress myocardial perfusion scan is negative for inducible ischemia. After initial stabilization, long-term use of which of the following medications will most likely improve survival in this patient?

Question

A 68-year-old man comes to the office due to several weeks of progressive exertional dyspnea and lower extremity edema.  Medical history is significant for non-Hodgkin lymphoma, which is in remission after chemotherapy 8 years ago.  Blood pressure is 126/76 mm Hg and pulse is 88/min.  Physical examination reveals bibasilar lung crackles and 1+ bilateral lower extremity edema.  Echocardiography shows biventricular dilation and a left ventricular ejection fraction of 35%.  Stress myocardial perfusion scan is negative for inducible ischemia.  After initial stabilization, long-term use of which of the following medications will most likely improve survival in this patient?

Quizplus · Accepted Answer

11ec160b_3b83_fe41_9249_055e22815b48_MD0001_00 This patient's clinical presentation is consistent with decompensated heart failure with reduced ejection fraction (HFrEF) (left ventricular [LV] systolic dysfunction with ejection fraction <40%). Given the absence of evidence of ischemia, this patient's presentation is most likely due to dilated cardiomyopathy as an adverse effect of chemotherapy for non-Hodgkin lymphoma. Beta blockers (eg, carvedilol, metoprolol) have been shown to improve long-term survival in patients with HFrEF. Much of the benefit of beta blockers in the treatment of HFrEF likely owes to neurohormonal blockade of sympathetic drive. This results in reduced heart rate and myocardial oxygen demand as well as decreased levels of circulating vasoconstrictors (eg, epinephrine, renin, endothelin), leading to reduced peripheral resistance (afterload) and myocardial work. These effects are cardioprotective, helping to reduce cardiomyocyte death and prevent deleterious cardiac remodeling. Beta blockers should not be initiated in patients with acute decompensated heart failure (ie, heart failure requiring hospitalization), as they can further impair cardiac output; they should be introduced slowly after the patient has been stabilized. Other drugs that improve long-term survival in patients with HFrEF include ACE inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors (eg, sacubitril-valsartan), and aldosterone antagonists (eg, spironolactone, eplerenone). (Choice A) Amiodarone is a class III antiarrhythmic agent used for the management of atrial fibrillation and ventricular tachycardia, but it is not used for heart failure. (Choices B and E) Dihydropyridine calcium channel blockers (eg, amlodipine) do not improve survival in patients with HFrEF. Nondihydropyridine calcium channel blockers (eg, diltiazem, verapamil) are specifically contraindicated in HFrEF due to the potential for reduced contractility and further worsening of LV systolic dysfunction. (Choice D) Digoxin is sometimes used as an adjunctive therapy in patients with HFrEF. It improves symptoms and reduces hospitalizations, but it has not been shown to improve survival. (Choice F) Flecainide is a class IC antiarrhythmic drug that is occasionally used for management of atrial fibrillation in patients with a structurally normal heart. It has no role in the management of heart failure. (Choice G) Loop diuretics (eg, furosemide) are first-line agents for volume control in patients with heart failure. They improve symptoms and reduce hospitalizations, but they have not been shown to improve long-term survival. Educational objective: Drugs that have been shown to improve long-term survival in patients with heart failure with reduced ejection fraction include beta blockers, ACE inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, and aldosterone antagonists. __________ References: 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23741057)

A 68-Year-Old Man Comes to the Office Due to Several