If possible, lithium should be discontinued for 3 months before reevaluation (SOR C). This duplicates the laboratory findings seen with mild primary hyperparathyroidism. Lithium therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland.
At this point in time, the patient described here does not meet any recommended criteria for further testing. An ankle-brachial index is reasonable for intermediate-risk, but not low-risk, patients. Measurement of cardiac calcium levels is reasonable in patients whose cardiovascular risk is intermediate (10-year risk 10%-20%) or low-to-intermediate (10-year risk 6%-10%). A C-reactive protein level may also be reasonable in younger patients with intermediate, but not low, cardiovascular risk. A C-reactive protein level can help to determine the need for statin therapy in men 50 and older and women 60 and older whose LDL-cholesterol levels are <130 mg/dL and who are not on lipid-lowering medication, hormone therapy, or immunosuppressive therapy, and who do not have clinical coronary heart disease, diabetes mellitus, chronic kidney disease, severe inflammatory disease, or contraindications to statins. The American College of Cardiology Foundation/American Heart Association guidelines for early cardiovascular assessment do not recommend lipoprotein and apolipoprotein levels. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure. Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block. The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%. This patient is already receiving maximal medical therapy. Refer for cardiac resynchronization therapy Increase the furosemide dosage to 160 mg dailyĮ. Increase the carvedilol dosage to 50 mg twice dailyĬ. Increase the lisinopril dosage to 80 mg twice dailyī. Which one of the following would be most appropriate at this time? (check one)Ī. An EKG reveals a left bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily carvedilol (Coreg), 25 mg twice daily and furosemide (Lasix), 80 mg daily. The patient is adherent to his medication regimen. He has shortness of breath with minimal exertion. Diabetes Care 2007 30(Suppl 1):S4-S41.Ī 72-year-old African-American male with New York Heart Association Class III heart failure sees you for follow-up. Ref: American Diabetes Association: Standards of medical care in diabetes-2007. TZDs should not be used in patients with New York Heart Association class III or IV heart failure. Insulin can also cause hypoglycemia, and injecting it requires good visual and motor skills and cognitive ability on the part of the patient or a caregiver. Sulfonylureas and other insulin secretagogues can cause hypoglycemia. Metformin is often contraindicated because of renal insufficiency or heart failure. Older patients can be treated with the same drug regimens as younger patients, but special care is required when prescribing and monitoring drug therapy. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy (SOR C). According to the American Diabetes Association guidelines, thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure.
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