A 56-year-old man comes to the office due to 3 months of dyspnea that was initially exertional but has progressively worsened to the point that the patient is now breathless even at rest. He has not had any chest pain, palpitations, syncope, or ankle swelling. The patient has no significant past medical history, and he takes no medications. He has been smoking a pack of cigarettes daily for the last 30 years and has been drinking alcohol heavily for the past 5 years. His mother died of breast cancer at age 57. The patient's temperature is 37.1 C (98.8 F), blood pressure is 113/76 mm Hg, and pulse is 86/min. A third heart sound is heard on cardiac auscultation; there are no murmurs. Chest auscultation indicates bibasilar crackles. His abdomen is soft and with no evidence of ascites. Laboratory results are as follows: Chest x-ray reveals cardiac silhouette enlargement and signs of pulmonary venous congestion. Echocardiography shows a dilated left ventricle with an estimated left ventricular ejection fraction of 25%. Coronary angiography reveals no evidence of obstructive coronary artery disease. Which of the following measures is most likely to reverse this patient's heart function?

Question

A 56-year-old man comes to the office due to 3 months of dyspnea that was initially exertional but has progressively worsened to the point that the patient is now breathless even at rest.  He has not had any chest pain, palpitations, syncope, or ankle swelling.  The patient has no significant past medical history, and he takes no medications.  He has been smoking a pack of cigarettes daily for the last 30 years and has been drinking alcohol heavily for the past 5 years.  His mother died of breast cancer at age 57.  The patient's temperature is 37.1 C (98.8 F), blood pressure is 113/76 mm Hg, and pulse is 86/min.  A third heart sound is heard on cardiac auscultation; there are no murmurs.  Chest auscultation indicates bibasilar crackles.  His abdomen is soft and with no evidence of ascites.  Laboratory results are as follows:  Chest x-ray reveals cardiac silhouette enlargement and signs of pulmonary venous congestion.  Echocardiography shows a dilated left ventricle with an estimated left ventricular ejection fraction of 25%.  Coronary angiography reveals no evidence of obstructive coronary artery disease.  Which of the following measures is most likely to reverse this patient's heart function?

Quizplus · Accepted Answer

This clinical presentation - dyspnea, third heart sound, bibasilar crackles, and low ejection fraction on echocardiogram - is consistent with decompensated congestive heart failure due to left ventricular (LV) systolic dysfunction. In this patient with no evidence of coronary artery disease on angiography, the most likely etiology is dilated cardiomyopathy due to heavy alcohol consumption (macrocytic anemia [mean corpuscular volume >100 µm³], thrombocytopenia, >2:1 ratio of aspartate aminotransferase to alanine aminotransferase). Alcoholic cardiomyopathy is a diagnosis of exclusion in patients with dilated cardiomyopathy and history of alcohol abuse in whom no other potential causes of cardiomyopathy (eg, coronary artery disease, valvular heart disease) are suspected or identified. The degree of LV dysfunction in alcoholic cardiomyopathy is directly related to the daily amount and overall duration of alcohol intake. The primary therapy for such patients is complete abstinence from alcohol use; this intervention is associated with improvement or normalization of LV function over time. (Choice B) Cigarette smoking is a strong risk factor for coronary heart disease, and smoking cessation should be encouraged in all patients, regardless of the presence or absence of coronary artery disease. However, tobacco cessation does not reverse the progression of alcoholic cardiomyopathy. (Choices C, D, and G) Patients with alcoholic cardiomyopathy should be managed in the same way as patients with other forms of dilated cardiomyopathy: salt and water restriction, diuretics as needed, ACE inhibitors or angiotensin II receptor blockers, beta blockers, mineralocorticoid receptor antagonists, and (if indicated) digoxin. However, strict abstinence from alcohol use remains the mainstay of therapy to reverse or halt further progression of cardiomyopathy. (Choice E) Niacin deficiency can occur with alcoholism, but supplementation has no role in management of patients with alcoholic cardiomyopathy. (Choice F) Glucocorticoid therapy (prednisolone) is occasionally used for patients with alcoholic hepatitis who have a high discriminant function, but it has no role in management of alcoholic cardiomyopathy. Educational objective: Complete cessation of alcohol consumption is the mainstay of therapy in patients with alcoholic cardiomyopathy and is associated with improvement or normalization of left ventricular function over time. References: Alcoholic cardiomyopathy: a review. (http://www.ncbi.nlm.nih.gov/pubmed/21962423) Natural history and prognostic factors in alcoholic cardiomyopathy. (http://www.ncbi.nlm.nih.gov/pubmed/25458176)

A 56-Year-Old Man Comes to the Office Due to 3