#69 - THE WEEKLY USMLE TIMES
Highlights for the week of April 1, 2024
Welcome to this week’s issue of The USMLE Times… A special welcome to the 85 new members who have joined our community this week.
Here’s what’s on tap for issue #69 of the USMLE Times:
Pharmacology / Internal Medicine Question
Video lesson of the week
Tweet of the week
This week’s training links
Question deep-dive & breakdown
Let’s dive in!
A 72-year-old female with a history of hypertension and type 2 diabetes presents to the emergency department with progressively worsening shortness of breath, orthopnea, and lower extremity edema over the past two weeks. She denies chest pain, fever, or cough. Her vital signs include a temperature of 98.6℉ (37°C), blood pressure of 150/90 mmHg, pulse of 100/minute, respiratory rate of 22/minute, and oxygen saturation of 91% on room air. On physical examination, jugular venous distention is noted, and lung auscultation revealed bilateral crackles at the lung bases. Cardiac auscultation reveals an S3 gallop and there is bilateral pitting edema in the lower extremities. A chest radiograph shows cardiomegaly and bilateral pulmonary vascular congestion. An echocardiogram reveals a left ventricular ejection fraction of 35%. She is given supplemental oxygen and IV furosemide, which provides some relief of her dyspnea. What is the most appropriate long-term management strategy for this patient?
A. Angiotensin-converting enzyme (ACE) inhibitor and beta-blocker
B. Angiotensin II receptor blocker (ARB) and calcium channel blocker
C. Digoxin and diuretics
D. Hydralazine and nitrates
E. Ivabradine and spironolactone
The answer & question breakdown is at the bottom of the post.
📺 WATCH
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💬 TWEET FOR THOUGHT
🔗 LINKS TO THIS WEEK’S TRAINING
April 1 - Biochemistry Drill Session - CLICK HERE
April 2 - Step 1 Genetics Question - CLICK HERE
April 3 - Step 1 GI Pathology Question - CLICK HERE
April 4 - Ask Dr. Paul (Q&A Thursday) - CLICK HERE
ANSWER + QUESTION BREAKDOWN
As a medical student, it's essential to recognize that this question assesses your knowledge of managing heart failure. The patient presents with classic signs and symptoms of acute decompensated heart failure, including shortness of breath, orthopnea, lower extremity edema, jugular venous distention, pulmonary crackles, and an S3 gallop. The chest radiograph and echocardiogram findings further support this diagnosis. The question asks for the most appropriate long-term management strategy for this patient.
ANSWER CHOICES:
ANSWER CHOICE A: Angiotensin-converting enzyme (ACE) inhibitor and beta-blocker
ACE inhibitors and beta-blockers are the cornerstone of heart failure management. ACE inhibitors reduce afterload and preload, while beta-blockers reduce heart rate and myocardial oxygen demand. Both have been shown to improve symptoms, reduce hospitalizations, and prolong survival in patients with heart failure with reduced ejection fraction (HFrEF).
ANSWER CHOICE B: Angiotensin II receptor blocker (ARB) and calcium channel blocker
ARBs can be used as an alternative to ACE inhibitors in patients who cannot tolerate them due to side effects such as cough. However, calcium channel blockers are not routinely recommended for managing HFrEF and may potentially worsen outcomes in some cases.
ANSWER CHOICE C: Digoxin and diuretics
Diuretics, such as furosemide, are used to manage fluid overload and relieve congestion symptoms in heart failure. Digoxin is an inotropic agent that can be used in patients with HFrEF to reduce symptoms and hospitalizations. However, digoxin is not considered first-line therapy and is typically reserved for patients who remain symptomatic despite optimal treatment with ACE inhibitors, beta-blockers, and diuretics.
ANSWER CHOICE D: Hydralazine and nitrates
The combination of hydralazine and nitrates can be used as an alternative to ACE inhibitors or ARBs in patients who cannot tolerate them, particularly in African American patients. However, they are not considered first-line therapy for HFrEF.
ANSWER CHOICE E: Ivabradine and spironolactone
Ivabradine is a heart rate-lowering agent that can be used in patients with HFrEF who remain symptomatic despite optimal treatment with ACE inhibitors, beta-blockers, and diuretics. Spironolactone is a mineralocorticoid receptor antagonist shown to reduce mortality and hospitalizations in patients with severe HFrEF. However, these medications are not typically used as initial therapy for HFrEF.
THE VERDICT: The combination of an ACE inhibitor and a beta-blocker is the most appropriate long-term management strategy for this patient with HFrEF. ACE inhibitors, such as lisinopril or enalapril, reduce afterload and preload by inhibiting the renin-angiotensin-aldosterone system, while beta-blockers, such as carvedilol or metoprolol succinate, reduce heart rate and myocardial oxygen demand. Both classes of medications have been shown to improve symptoms, reduce hospitalizations, and prolong survival in patients with HFrEF.
While potentially useful in certain situations, the other answer choices are not considered first-line therapy for the initial management of HFrEF.
FINAL ANSWER: A. Angiotensin-converting enzyme (ACE) inhibitor and beta-blocker
That’s all for issue #69 of The USMLE Times!
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