A patient with syncope

[rajupangeni]

hello junus, ACE inhibitors are contraindicated in following cases:
• Angioedema
• Aortic stenosis
• Hyperkalemia
• Hypotension
• Renal artery stenosis
• Worsening renal function/renal disease/dysfunction
... and sometimes in uncontrolled cough, if other causes are ruled out.. however, recent studies have shown that it could still be used in mild or moderate cases of asymptomatic AS.. The British National Formulary advises caution but does not explicitly contraindicate its use in severe and symptomatic forms of AS.. this is primarily due to concern of invoking profound peripheral vasodilation that wud result in hypotension, collapse and potentially increased risk of sudden death.. so, for routine use i think we should take it as a contraindication..
For other causes of cardiac failure, as in myocardial infarction, ACE inhibitors are the mainstay of long term therapy, never forget 3 As and a B in MI.. Aspirin, Atorvastatin (lipid lowering) and ACE inhibitors plus a Beta Blocker..
For this patient, i'd confirm AS first, and then choose between ACE inhibitor (as he is a diabetic), or a diuretic.. Nowadays beta blockers are not contraindicated and in fact, decrease mortality, in mild forms of cardiac failures..
To sum up, the question needs some more information!

[Walrus]

Originally Posted by rajupangeni

3 As and a B in MI.. Aspirin, Atorvastatin (lipid lowering) and ACE inhibitors plus a Beta Blocker..
For this patient, i'd confirm AS first,

And, what about Morphine? Please tell me if it has been removed from the protocol. (May be we can start a new thread regarding management of MI - discussion rather than copy-paste from some website)

This case, I would say is not AS and rather could be Hypertrophic Cardiomyopathy with HTN.

[rajupangeni]

walrus, thanks for that post...
u are right, those findings support Hypertrophic Obstructive Cardiomyopathy.. not AS.. (hypertensive heart disease is different) All findings will fit in only if the patient has preexisting hypertension as well.

in that case, beta blockers and then calcium channel blockers would be considered first line of management.

hypertensive heart disease/hypertensive cardiomyopathy, ischaemic cardiomyopathy and hypertrophic cardiomyopathy with HTN are totally different entities.

[rajupangeni]

hi walrus, i was talking about long term management of MI.. acute management will always include MONABHAI.. ( morphine, O2, nitrates, aspirin, beta blockers, heparin or thrombolysis, atorvastatin, and invasive diagnostic or therapeutic procedures)

[Soul]

Great ..finally I got the right answer. Well this pt has new episode of syncope on exertion which suggests 2 things first: Aortic stenosis (AS) and Hypertrophic cardiomyopathy (HCM). Moreover, he has systolic ejection murmur at LSB.

i think the question itself creates some confusion.. it seems that the patient is having aortic stenosis, though the murmur of AS is audible mostly in right upper sternal border rather than LSB

rajupangeni is right that the murmur in AS is heard in 2nd RICS, but in HCM it is best heard in LSB. This is a case of HCM. You all didn't notice the physical exam...

systolic ejection murmur at LSB, which increases with Valsalva manouver

Murmur of HCM increases in intesity with valsalva. This also helps you to differentiate from AS.
Echo and Left ventrulography was done and a diagnosis of HCM was confirmed.
Now treatment: It is now confirmed that this patient has HCM with preexisting HTN. As you all know, HTN is best treated with Diuertics, ACE-I, CCB, and BB (either mono or in combi). Since this is a case of HCM, vasodilators should be best avoided, so ACE-I should not be used. rajupangeni has already mentioned why ACE-I should not be used in AS (similar for HCM), but to be more precise, ACE-I increases ventricular emptying, thus will worsen the obstruction in a patient who already has serious signs of LVOT obstruction. Though ACE-I is good for HTN in a DM pt, but the issue here is to prevent hemodynamic compromise. Remember one thing: anything which decreases the preload will lead to increase in LVOT obstruction, therefore diuretics are best avoided in this case. Diuretics decrease LV filling (preload) thus worsen the LVOT obstruction. (This is the mechanism why Valsalva increases intensity of murmur in HCM, Valsalva manouever decreases LV filling).
HTN in this pt should be treated with BB, coz BB is also the drug of choice in HCM. BB decreases the force of contraction and thus decreses the obstruction (mumur will be significantly decreased in intensity or will disappear). Moreover, BB increases LV diastolic filling by decreasing HR, and thus decreases the obstruction. Remember: anything which increases LV filling will decrease the obstruction, eg Squatting).
CCB is not the first line therapy for HCM, they should be used if BB is not responsive or if BB is intolerant. However, some suggest that CCB can be added with BB if severe HCM.
Hope you are satisfied with the explanation. Comments are welcomed! ^_^

[Soul]

Echo and Left ventrulography was done and a diagnosis of HCM was confirmed.

Left ventrulography = Left ventriculography

[rajupangeni]

nice discussion soul, thanks for that.. i'd totally missed that valsalva thing.. it was a nice reminder of those forgotten things.
keep it up!

[JNUS]

Great discussion, Me too regarding, area of the murmur and valsalva Maneuover.
Thanks a lot for the case.

[Walrus]

I have to review my lessons now. I got the diagnosis right but I messed up the management which is not good. But, ACE-I is good for HTN with LVH and not good for Valvular stenosis. This case is not valvular stenosis but sub-valvular. Is it considered not good in that case also?

[Soul]

Yup similar effect of ACE-I in those conditions. When there is pressure gradient better not to use any vasodilators, for this reason CCB is also used with caution in HCM.

ACE-I is a good drug which can reverse cardiac hypertrophy, but it is true for those conditions in which hypertrophy is due to pressure overload. I remind you that the molecular basis of hypertrophy in HCM is different coz hypertrophy in HCM is not due to pressure overload, it is due to a myocardial disease, and studies have clearly demonstrated that ACE-I doesnot regress the hypertrophy in HCM, but leads to development of pressure gradient or worsen the pressure gradient. ( I have already mentioned this in my previous post)

BUT, if there is overt heart failure (gradually HCM may change into DCM with thinning of ventricular muscle and marked systolic dysfuntion), ACE-I is used in that condition (just as in CHF).