Question of the Week # 342

342) A 65 year old man presents with progressively increasing shortness of breath. He has a 100 pack year history of smoking. His past medical history is significant for coronary artery disease and congestive heart failure. He has been admitted several times in the past one year for Congestive heart failure exacerbations which resulted from his non-compliance with diet and medications. His medications include aspirin, metoprolol, enalapril, and spironolactone and tiotropium inhaler. On examination, he is afebrile with respiratory rate 24/min, pulse 106beats/min, blood pressure 140/90. Crepitations are heard at bilateral lung bases and breath sounds decreased bilaterally.  A 2D echocardiogram reveals ejection fraction at 30% . An EKG reveals changes consistent with left ventricular hypertrophy. A Chest X-ray shows moderate pleural effusions bilaterally. Which of the following is the most appropriate next step in management of pleural effusion?

A) Intravenous Furosemide

B) Tube Thoracostomy

C) Tube thoracostomy followed by Pleurodesis

D) Needle thoracentesis

E) Implantable Cardioverter-Defibrillator (ICD) placement

10 Responses

  1. A) Intravenous Furosemide

    • B

  2. A

  3. A—-bilateral pleural effusion —treated with medication—-this is CHF

  4. A

  5. EF 30 ( most important) + LVH + CCF
    my answer is E

  6. All the medical management is given for CCF.
    No pulmonary edema on CXR.

  7. A?
    HF-associated effusions are typically bilateral, but if unilateral, they are more commonly seen on the right side.
    Loop diuretics are the mainstay of therapy, although a therapeutic thoracentesis for very large effusions may occasionally be required.
    https://www.ncbi.nlm.nih.gov/pubmed/21213200

    Indications for ICDs in patients with heart failure
    *2o prevention : haemodynamically unstable ventricular tachycardia or ventricular fibrillation
    *1o prevention: LVEF <30% who are in NYHA Class II-III despite medial Rx.

    Am I correct ?

  8. Sorry for the typo – LVEF <35%

  9. Also Cardiac resynchronisation therapy (CRT) advanced HF (NYHA functional Class III and ambulatory Class IV) who have a left ventricular ejection fraction under 35%, who are in sinus rhythm, and have a QRS duration above 120 ms.

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