A 65-year-old female is admitted to the hospital with increasing shortness of breath, weight gain and lower extremity edema. She has a history of hypertension, nonischemic cardiomyopathy with an ejection fraction of 30%, and hyperlipidemia. Her home medications include oral aspirin, digoxin, furosemide, metoprolol, lisinopril and atorvastatin. She is started on intravenous furosemide. On day three of hospitalization telemetry reveals six beats of wide complex ventricular tachycardia. Physical examination now shows decreased leg edema and clear lungs. Which of the following is the most appropriate next step in the management of this patient's tachycardia?

Question

A 65-year-old female is admitted to the hospital with increasing shortness of breath, weight gain and lower extremity edema.  She has a history of hypertension, nonischemic cardiomyopathy with an ejection fraction of 30%, and hyperlipidemia.  Her home medications include oral aspirin, digoxin, furosemide, metoprolol, lisinopril and atorvastatin.  She is started on intravenous furosemide.  On day three of hospitalization telemetry reveals six beats of wide complex ventricular tachycardia.  Physical examination now shows decreased leg edema and clear lungs.  Which of the following is the most appropriate next step in the management of this patient's tachycardia?

Quizplus · Accepted Answer

When a patient experiences recurrent VT (ventricular tachycardia), the first thing to do after stabilizing the patient is to search for an underlying cause. This patient most likely has an electrolyte imbalance due to diuretics. Furosemide commonly causes hypokalemia and hypomagnesemia. If uncorrected, both hypokalemia and hypomagnesemia can lead to ventricular tachycardia. Furthermore, hypokalemia potentiates side effects of digoxin, which include arrhythmias such as ventricular tachycardia. Therefore, ordering serum electrolytes and serum digoxin level is the most reasonable initial approach. (Choice A) Spironolactone is a potassium sparing diuretic, and has proven mortality benefits in patients with severe CHF. It would be of benefit in the long-term management of this patient, and could balance out the potassium wasting caused by furosemide. However, immediate identification and reversal of the underlying cause of this patient's VT is the priority. (Choice B) Metolazone is a thiazide diuretic. Adding another diuretic is unnecessary because the patient's fluid overload has resolved. In addition, metolazone could further worsen her electrolyte imbalances and increase her risk of developing recurrent ventricular tachycardia. (Choice D) Stopping the patient's atorvastatin is unnecessary because it does not cause ventricular arrhythmias and the patient needs it to treat her hyperlipidemia. (Choice E) Beta-blockers should be avoided in acute decompensated heart failure due to systolic dysfunction. However, the patient's congestive symptoms have now improved so holding the metoprolol is currently unnecessary. Metoprolol does not cause ventricular arrhythmias. Educational objective: Loop diuretics cause hypokalemia and hypomagnesemia. These electrolyte abnormalities can cause ventricular tachycardia, and also potentiate the side effects of digoxin.

A 65-Year-Old Female Is Admitted to the Hospital with Increasing