Question. Is it C or D?

[Shaikhoo]

A 70 year-old man was admitted to the hospital one week ago with acute decompensated heart failure. Currently, he can walk about 200 yards around the hospital ward before stopping because of fatigue and shortness of breath. Medical history is significant for nonischemic cardiomyopathy, with an implantable cardioverter-defibrillator placed one year ago. He has mild (stage 1) COPD. Medications while in the hospital are lisinopril, bumetanide, digoxin, spironolactone, and an albuterol inhaler, used as needed.

On PE, blood pressure is 90/70 mm Hg, and pulse is 80/min. A grade 2/6 holosystolic murmur is heard at the left sternal border radiating to the apex. No jugular venous distention is present, lungs are clear to auscultation, no S3 is heard, and there is no edema.

The EKG shows a QRS duration of 110 msec and normal sinus rhythm. Echocardiogram shows an EF of 20%, left ventricular enlargement, and moderate mitral regurgitation but otherwise no anatomic abnormalities of the mitral valve (unchanged from previous echocardiogram 1 year ago.)

Which of the following is the most appropriate treatment?

A. Refer for mitral valve repair
B. Replace spironolactone with eplerenone
C. Start metoprolol succinate
D. Upgrade to a biventricular pacemaker with implantable cardioverter-defibrillator

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[FOLLOWYOURHEART]

C?

According to MTB 2:
Indication for biventricular pacemaker: QRS complex greater than 120 msec & ejection fraction less than 35%
and
beta blockers (bisoprolol,metoprolol and carvedilol) have mortality benefits in systolic dysfunction

Please let us know if you find out the answer

 

[Apoplexy__]

I vote D. His QRS is prolonged, so he would benefit from improved synchrony. Metoprolol probably doesn't have much of a benefit since the cardiomyopathy is nonischemic and he doesn't appear to have an arrhythmia. I'm not sure if it matters, but he also might not want to be on a B-blocker if he's getting acute decompensations.

FOLLOWYOURHEART makes a good point about the QRS > 120 msec threshold, but I'm not sure how set in stone that is since UptoDate's biventricular pacemaker article seems to have a couple different msec thresholds depending on the circumstances.

I honestly don't know though. I'd like to know the answer too.

 

[CaliAtenza]

Well, UpToDate says this: "We suggest CRT in patients with LVEF ≤35 percent, NYHA functional class III, or ambulatory class IV on optimal medical therapy with non-LBBB pattern with a QRS duration of ≥150 ms (Grade 2B)",

This concept isn't touched upon in Uworld at all though.

 

[Phloston]

Dude, look at his blood pressure. Why would you start an additional BP-lowering med in someone like that. "Hey, you've got a systolic of 90. Let's start you on a beta-blocker." Just no.

His EF is absurdly low. That's why his BP is low. A beta-blocker isn't going to improve that. Spironolactone is good for systolic dysfunction for indirect afterload reduction, but he's already on it. He clearly needs pacing.

The answer is D. And if I'm wrong, then this would be a ******ed question.

And btw, MTB isn't reliable.

 

[CaliAtenza]

Dude, look at his blood pressure. Why would you start an additional BP-lowering med in someone like that. "Hey, you've got a systolic of 90. Let's start you on a beta-blocker." Just no.

His EF is absurdly low. That's why his BP is low. A beta-blocker isn't going to improve that. Spironolactone is good for systolic dysfunction for indirect afterload reduction, but he's already on it. He clearly needs pacing.

The answer is D. And if I'm wrong, then this would be a ******ed question.

And btw, MTB isn't reliable.

Lol more than pacing, dude needs a new Heart...

 

[Apoplexy__]

FWIW, I just stumbled across a problem just like this in the AAFP online questions (the ones used for re-cert). The correct answer for a patient just like this (EF 25%, no QRS specified, NYHA III/IV on extensive medical therapy) was cardiac resynchronization therapy (biventricular device).

 

[CaliAtenza]

FWIW, I just stumbled across a problem just like this in the AAFP online questions (the ones used for re-cert). The correct answer for a patient just like this (EF 25%, no QRS specified, NYHA III/IV on extensive medical therapy) was cardiac resynchronization therapy (biventricular device).

I mean even if you didn't know that, you could infer from the stem that a new device would have to be the answer.