MEDizzy - A 72-year-old Caucasian male presents with shortness of

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Cardiology

A 72-year-old Caucasian male presents with shortness of breath that awakens him at night. At baseline, he is able to walk less than a block before stopping to catch his breath. Physical examination findings include bilateral basilar rales and neck vein distention. The patient has a known history of congestive heart failure, and his last echocardiogram revealed an ejection fraction of 25%. The patient is compliant with a medication regimen including an ACE inhibitor, beta-blocker, and loop diuretic. Blood pressure is well controlled. What additional treatment should you begin next?

ExplanationACE inhibitors and beta-blockers are the basic regimens for patients with CHF and a depressed ejection fraction. The addition of spironolactone has been shown to be beneficial in the management of CHF in patients with New York Heart Association Class III or IV heart failure and an ejection fraction less than 35%. NYHA Class III patients have marked limitations, with symptoms on less than usual activities. NYHA Class IV patients are dyspneic at rest. Although aspirin, warfarin, or amlodipine may be given for other indications, they are unlikely to improve his CHF symptoms. The combination of hydralazine and isosorbide dinitrate has been shown to be advantageous in African Americans who remain symptomatic on ACEIs and beta-blockers.