MKSAP Case study: ischemic cardiomyopathy


ACP Internist has brought back its MKSAP quiz. This popular feature was so heavily requested by our readers that we're restoring it in our print edition and ACP InternistWeekly e-mail updates.

Case study:

A 50-year-old black man with ischemic cardiomyopathy presents for a routine follow-up. His medical history is significant for biventricular pacemaker/cardioverter-defibrillator placement and diabetes mellitus. He develops shortness of breath from ascending less than 1 flight of stairs or walking less than 1 block on level ground, a symptom that has been stable. His medications include aspirin, lisinopril, carvedilol, isosorbide mononitrate, furosemide, spironolactone, digoxin, atorvastatin, and insulin. His blood pressure is 105/78 mm Hg and his heart rate is 62/min.

Physical examination reveals clear lungs, a regular cardiac rhythm, grade 2/6 systolic murmur at the apex, and no peripheral edema. A recent echocardiogram showed left ventricular enlargement, severely decreased systolic function (left ventricular ejection fraction, 15%), and mild mitral regurgitation.

Which of the following medications should be added?

A. Amiodarone
B. Clopidogrel
C. Hydralazine
D. Nesiritide

Answer: C. Hydralazine. The complete MKSAP syllabus and critique on this topic is available to subscribers in Cardiovascular Medicine: Item 121.