Answers

L C. The most likely diagnosis is ACE inhibitor-induced cough. A reasonable approach is to substitute an ARB (angiotensin II receptor blocker) such as valsartan or losartan for the ACE inhibitor, cap-topril. Reassure and encourage the patient and spouse that you think the cough will resolve a few days after stopping the ACE inhibitor. There is generally no benefit to trying any other ACE inhibitor, as the side effect is a class effect resulting from enhanced kinin activity from ACE inhibition. Myocardial infarction is extremely unlikely in this patient based on the catheterization data showing normal coronary anatomy. Abrupt withdrawal of a p-blocker may precipitate tachycardia and hypertension and should be avoided. 2. A. This woman with CHF has obviously decom-pensated despite compliance with standard care. She is symptomatic and may benefit from a short course of high-intensity intravenous therapy with a cAMP-elevating agent (e.g., dobutamine, milrinone, amrinone). This may be a reversible event or part of the inevitable decline of the disease process. Approximately 45% of CHF patients die suddenly of a presumed electrical event (e.g., ventricular tachycardia, asystole). The others die slowly of progressive deterioration. Many patients at the end stages of CHF prefer to try repeated outpatient in-otropic (cAMP elevating) therapy for symptomatic relief even though it may be associated with a higher incidence of sudden death.

3. D. Inhibition of Na-K ATPase leads to an elevation of intracellular Na+. This results in an increase in intracellular Ca++ and an enhanced myocardial contractibility. There is no definitive evidence that digitalis improves survival of patients in heart failure, but it clearly improves the symptoms of this condition.

4. B. Prazosin has been shown not to be as effective as the combination of hydralazine and nitrates.

5. A. The salutary effect of p-blockers appears to be due solely to its binding to the p-receptor, which prevents norepinephrine binding and stimulates cAMP formation. The other choices do not occur.

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