64 yo M presents to establish care. Has CAD, HTN,
DM-II. He feels well, had recent
negative stress test with his cardiologist, has good exercise tolerance. Meds are metofromin/glipizide, metoprolol, ASA, lisinopril,
fish oil and atorvastatin. Labs: Cr 1.1, A1c 7.1, HDL 30, LDL 68, U protein/CR
Ratio 450mg/day. Echo shows EF 40%.
What should you do:
Add Niacin
Change MTP to Coreg
Add Losartan- Correct Answer
Change glipizide to insulin basal/bolus
This patient's CAD is well controlled and though he has a low EF he does not have clinical evidence of CHF. The patient's EF does not necessitate a change to carvedilol
. The landmark Comet Trial compared long-acting Metoprolol (Toprol XL) to Carvedilol (Coreg) in NYHA Class II-V CHF with EF 35% or less. The results showed improvement in these patients with Carvedilol. This patient does not have symptomatic CHF and his EF is 40% so he does not meet inclusion criteria for this trial and thus does not have in indication for a change in Beta Blocker Therapy.
The patient's LDL is a at goal, and he is on fish oil, however he has low HDL. Currently there are limited effective therapy to raise HDL other than statins and fish oil. Niacin is controversial.
The patient's A1c is at/near goal, there is no indication to change his hypoglycemics to insulin at this time. However, the patient has evidence of nephropathy, and his proteinuria is not controlled by his ACE-I. Thus he requires dual RAAS inhibition, which will confer now additional anti-hypertensive benefit but will decrease his proteiuria,.
The patient's LDL is a at goal, and he is on fish oil, however he has low HDL. Currently there are limited effective therapy to raise HDL other than statins and fish oil. Niacin is controversial.
The patient's A1c is at/near goal, there is no indication to change his hypoglycemics to insulin at this time. However, the patient has evidence of nephropathy, and his proteinuria is not controlled by his ACE-I. Thus he requires dual RAAS inhibition, which will confer now additional anti-hypertensive benefit but will decrease his proteiuria,.
Adding an ARB is currently not recommended in patients with CHF on an ACEi + BB but still symptomatic. A Cochrane review of outcomes of ARB plus ACE inhibitor therapy to ACE inhibitor therapy alone in patients with HF was dominated by the Val-HeFT and CHARM-Added results [3,12,13]. There were no statistically significant differences in total mortality (RR 0.98, 0.90-1.06), cardiovascular mortality, or non-cardiovascular mortality between combined ARB plus ACE inhibitor and ACE inhibitor monotherapy. Combination therapy reduced hospitalization for HF compared to ACE inhibitor therapy (RR 0.81, 95% CI .074, 0.89) but did not reduce total hospitalizations. Withdrawals due to adverse effects were more frequent with combination therapy
Poole-Wilson PA et al Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial.
Lancet. 2003 Jul 5;362(9377):7-13.
Cohen DL, and Townsend RR Is There Added Value to Adding ARB to ACE Inhibitors in the Management of CKD?JASN August 1, 2009 vol. 20 no. 8 1666-1668
