By Eugene C. Toy, John T. Patlan Jr.
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Additional resources for Case Files Internal Medicine
This patient’s systolic murmur is consistent with aortic stenosis. An evaluation should include echocardiography to conﬁrm the diagnosis, and then aortic valve replacement. 4 A. When the ejection fraction exceeds 40%, there is likely diastolic dysfunction, with stiff ventricles. The stiff thickened ventricles do not accept blood very readily. This patient has symptoms with mild exertion that are indicative of functional class III. The worst class is level IV, manifested as symptoms at rest or with minimal exertion.
Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and some beta-blockers, such as carvedilol (CAR), metoprolol, or bisoprolol, have been shown to reduce mortality in patients with impaired systolic function and moderate to severe symptoms. In patients who cannot tolerate ACE inhibition (or in black patients in whom ACE inhibitors appear to confer less benefit), the use of hydralazine with nitrates has been shown to decrease mortality. Aldosterone antagonists such as spironolactone may be added to patients with NYHA class III or IV heart failure with persistent symptoms, but patients should be monitored for hyperkalemia.
Next step: Cardiac rate control with intravenous beta-blockers. ANALYSIS Objectives 1. Know the causes of atrial fibrillation. 2. Understand the management of acute atrial fibrillation with rapid ventricular response. 3. Understand the rationale for anticoagulation in chronic atrial fibrillation. 4. Know the typical cardiac lesions of rheumatic heart disease and the physical findings in mitral stenosis. 5. Understand the physiologic basis of Wolff-Parkinson-White syndrome and the special considerations in atrial fibrillation.