Examkin

Soru

Zorluk: ZorPharmacologic Interventions

A 59-year-old woman is evaluated in the intensive care unit shortly after admission for progressive dyspnea, orthopnea, and confusion over the past 48 hours. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 20%, type 2 diabetes mellitus, and chronic kidney disease stage 3. Her home medications include sacubitril-valsartan, metoprolol succinate, spironolactone, dapagliflozin, and oral torsemide.

Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/54 mm Hg, pulse 114/min, and respirations 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals lethargy and confusion. The jugular venous pressure is estimated at 14 cm H2O. Auscultation of the lungs reveals diffuse bilateral crackles extending to the apices. Cardiac examination shows a regular tachycardia with a prominent S3 gallop. The extremities are cool to the touch and mottled, with a capillary refill time of 5 seconds.

Laboratory studies show:
Serum sodium: 132 mEq/L
Serum potassium: 3.3 mEq/L
Serum creatinine: 2.1 mg/dL (baseline 1.5 mg/dL)
B-type natriuretic peptide (BNP): 1,450 pg/mL
High-sensitivity troponin T: 34 ng/L (normal < 14 ng/L)

Electrocardiogram shows sinus tachycardia with a left bundle branch block, unchanged from prior.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Continue metoprolol succinate at the current dosage
  2. B
    Initiate intravenous phenylephrine to improve blood pressure
  3. Withhold the home dose of metoprolol succinateCevap
  4. D
    Delay intravenous diuresis until serum potassium is repleted
  5. E
    Order a comprehensive echocardiogram before administering inotropes

Cevap

Withhold the home dose of metoprolol succinate
This patient presents with acute decompensated heart failure manifesting as cardiogenic shock. Her clinical profile is 'cold and wet,' characterized by severe volume overload (pulmonary crackles, jugular venous distention) and significant tissue hypoperfusion (hypotension, confusion, cold/mottled extremities, delayed capillary refill). In patients with this hemodynamic profile, home beta-blockers (such as metoprolol succinate) must be immediately withheld. Their negative inotropic and chronotropic effects further depress cardiac output and exacerbate systemic hypoperfusion. The appropriate management includes withholding the beta-blocker, providing noninvasive positive pressure ventilation, administering loop diuretics (while closely monitoring hemodynamics), and initiating intravenous inotropic support (e.g., dobutamine or milrinone) to improve forward cardiac output.

Adım Adım Çözüm

1
Interpret the clinical presentation and vital signs.
The patient has hypotension, tachycardia, confusion, and cold/mottled extremities indicating hypoperfusion, along with crackles and elevated JVP indicating severe volume overload.
This establishes the hemodynamic profile as cardiogenic shock, specifically the 'cold and wet' phenotype of acute decompensated heart failure (ADHF).
2
Evaluate the patient's home medication list in the context of her hemodynamic status.
The patient takes metoprolol succinate, a beta-blocker.
Identifying home medications that are contraindicated in the acute setting is a critical step in stabilization.
3
Determine the appropriate pharmacologic adjustment.
The beta-blocker must be immediately withheld.
Beta-blockers have negative inotropic effects that will further depress cardiac output and exacerbate systemic hypoperfusion in cardiogenic shock.

Anahtar Kavram

Management of acute decompensated heart failure (ADHF) phenotypes, specifically recognizing cardiogenic shock ('cold and wet' profile) as an absolute indication to withhold beta-blocker therapy.
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Pharmacologic Interventions

Bu konudan daha fazla soru