A 65-year-old man comes to the physician after missing a follow-up appointment for congestive heart failure. He missed his appointment due to an upset stomach that will not go away. A detailed history reveals disturbed color perception, anorexia, nausea, vomiting, and diarrhea that have worsened over the past 2 weeks. His congestive heart failure has thus far been controlled effectively with multiple medications. If the cause of this patient's current symptoms is not corrected, which of the following complications is most likely to develop?

Question

A 65-year-old man comes to the physician after missing a follow-up appointment for congestive heart failure.  He missed his appointment due to an upset stomach that will not go away.  A detailed history reveals disturbed color perception, anorexia, nausea, vomiting, and diarrhea that have worsened over the past 2 weeks.  His congestive heart failure has thus far been controlled effectively with multiple medications.  If the cause of this patient's current symptoms is not corrected, which of the following complications is most likely to develop?

Quizplus · Accepted Answer

11ec160b_3b86_e476_9249_cf1cdbdd2532_MD0001_00 This patient most likely has chronic digoxin toxicity, which can cause nonspecific gastrointestinal and neurologic symptoms. Although rare, changes in color vision are particularly associated with digoxin overdose. The most serious complication of digoxin toxicity is the development of potentially fatal cardiac arrhythmias of virtually any type. Digoxin has a narrow therapeutic index, making toxicity relatively common. Precipitating causes include hypokalemia (increased digoxin binding), hypovolemia, and renal failure. Patients with severe toxicity (eg, life-threatening arrhythmias, end-organ dysfunction) are treated with anti-digoxin antibody fragments. (Choice A) Angioedema is a severe side effect that manifests as rapidly developing edema that often affects the lips and larynx. Of the drugs used to treat heart failure, angiotensin-converting enzyme inhibitors are most commonly associated with angioedema. (Choice C) Bronchoconstriction can be caused by nonspecific beta-adrenergic blockers (eg, propranolol) in patients with chronic obstructive pulmonary disease or asthma. Selective beta blockers (eg, metoprolol) are commonly used to treat patients with congestive heart failure and are less likely to cause bronchoconstriction. (Choice D) Hypotension can occur with digoxin toxicity due to bradyarrhythmias and severe vomiting and diarrhea that lead to hypovolemia. However, digoxin is also an inotropic agent that causes increased cardiac output. Therefore, hypotension is a variable manifestation of digoxin toxicity. (Choice E) Pulmonary edema may occur with uncontrolled heart failure due to poor forward flow that causes blood to pool in the lungs. It can be caused by both systolic and diastolic left ventricular dysfunction due to decreased forward ejection of blood and impaired ventricular filling, respectively. Educational objective: Digoxin toxicity presents with nonspecific gastrointestinal (eg, anorexia, nausea, vomiting) and neurologic (eg, fatigue, confusion, weakness) symptoms. Changes in color vision are a more specific, but rarer, finding. Life-threatening ventricular arrhythmias are the most serious complication. __________ References: Diagnosis and treatment of digoxin toxicity. (http://www.ncbi.nlm.nih.gov/pubmed/8346128) Digitalis toxicity: a fading but crucial complication to recognize. (http://www.ncbi.nlm.nih.gov/pubmed/22444097)

A 65-Year-Old Man Comes to the Physician After Missing a Follow-Up