Case Study Therapy for Inoperable Coronary Artery Disease
A 75-year-old man has inoperable coronary artery disease with an EF of 31%. He is receiving digoxin, furosemide, and an ACE inhibitor. He is unable to walk more than 50 feet on flat ground before getting short of breath (dyspnea on exertion at 50 feet). His heart rate at rest is 85 beats per minute and his blood pressure while seated is 130/85. His neck veins are flat; carotid upstrokes are normal; lungs are clear; and heart examination reveals no murmurs, gallops, or rubs. His extremities reveal no cyanosis, clubbing, or edema. The remainder of the physical examination is unremarkable. What is your next therapeutic option?
Answer: Start a low-dose p-adrenergic blocker. Presently the choices are either the p1-selective adrenergic blocker, metoprolol, or the combined nonselective p- and a-adrenergic blocker carvedilol. The target heart rate at rest should be in the range of 50 to 60 beats per minute. The target blood pressure should be in the range of 90 to 110 systolic, or orthostatic symptoms of light-headedness develop.
Peter S. Fischbach and Benedict R. Lucchesi
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