P-treatment

• CASE STUDY

• A 35-year-old man presents with a blood pressure of 150/95 mm Hg. He has been generally

healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a

family history of hypertension, and his father died of a myocardial infarction at age 55. PhysicalA

35-year-old man presents with a blood pressure of 150/95 mm Hg. He has been generally

healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a

family history of hypertension, and his father died of a myocardial infarction at age 55. Physical

examination is remarkable only for moderate obesity. Total cholesterol is 220 and high-density

lipoprotein (HDL) cholesterol level is 40 mg/dL. Fasting glucose is 105 mg/dL. Chest x-ray is

normal. Electrocardiogram shows left ventricular enlargement. How would you treat this

patient?

• CASE STUDY

• A 74-year-old man presents with a history of anterior chest pressure whenever he walks more than one block. The chest discomfort is diffuse, and he cannot localize it; sometimes it radiates to his lower jaw. The discomfort is more severe when he walks after meals but is relieved within 2–3 minutes when he stops walking.

• What medical treatments should be implemented to reduce the acute pain of an attack, to prevent future attacks, and to reduce the chance of blood clotting?

• CASE STUDY • A 50-year-old man has developed shortness of breath with exertion

several weeks after experiencing a viral illness. This is accompanied by swelling of the feet and ankles and some increasing fatigue. On physical examination he is found to be mildly short of breath lying down, but feels better sitting upright. Pulse is 105 and regular, and blood pressure is 90/60 mm Hg. His lungs show crackles at both bases, and his jugular venous pressure is elevated. A third heart sound is present but no murmurs are heard on auscultation of the heart. The liver is enlarged, and there is 3+ edema of the ankles and feet. An echocardiogram shows a dilated, poorly contracting heart with a left ventricular ejection fraction of about 20% (normal: 60%). Because of an abnormal ECG, he undergoes a coronary angiogram, which shows normal coronary arteries.

• He is placed on a low-sodium diet and treated with a diuretic (furosemide 40 mg twice daily) and digoxin 0.25 mg daily. On this therapy, he is less short of breath on exertion and can also lie flat without dyspnea. An angiotensin-converting enzyme (ACE) inhibitor is added (enalapril 20 mg twice daily), and over the next few weeks he continues to feel better. Three months after the first visit, the man is asymptomatic at rest and with mild exercise. Heart rate is 80, and blood pressure is 110/70. A repeat echocardiogram shows that his heart is smaller (though not back to normal) and his left ventricular ejection fraction has improved to 40%. What other pharmacologic options are available if this man’s disease remains stable?

• What treatments are available if his heart failure suddenly becomes worse?

• CASE STUDY • A 69-year-old retired teacher presents with a 1-

month history of palpitations, intermittent shortness of breath, and fatigue. She has a history of hypertension. An ECG shows atrial fibrillation with a ventricular rate of 122 per minute and signs of left ventricular hypertrophy. She is anticoagulated with warfarin and started on sustained-release metoprolol 50 mg/d. After 7 days, the patient’s rhythm reverts to normal sinus spontaneously.

• However, over the ensuing month, she continues to have intermittent palpitations and fatigue. Continuous ECG recording over a 48-hour period documents paroxysms of atrial fibrillation with heart rates of 88–114 bpm. An echocardiogram shows a left ventricular ejection fraction of 38% with no localized wall motion abnormality.

• At this stage, would you initiate treatment with an antiarrhythmic drug to maintain normal sinus rhythm, and if so, what drug would you choose?

• CASE STUDY

• A 25-year-old woman presents to the emergency department complaining of acute onset of shortness of breath and pleuritic pain. She had been in her usual state of health until 2 days prior when she noted that her left leg was swollen and red. Her only medication was oral contraceptives. Family history was significant for a history of “blood clots” in multiple members of the maternal side of her family. Physical examination demonstrates an anxious woman with stable vital signs.

• The left lower extremity demonstrates erythema and edema and is tender to touch. Ultrasound reveals a deep vein thrombosis in the left lower extremity; chest computed tomography scan confirms the presence of pulmonary emboli.

• What are the likely risk factors in this woman—hereditary, acquired, or both?

• What therapy is indicated acutely? • What are the long-term therapy options? • How long should she be treated? • Should this individual use oral contraceptives?

• Next

• Contraceptive

• Hormons