Paper I
Question
A 50 year old man develops pedal edema and also has difficulty in breathing. Echocardiography confirms mild congestive cardiac failure. Answer the following:
- (a) What are the first line drugs in congestive cardiac failure. 1 mark(s)
- (b) What is the rationale for use of each of them in congestive cardiac failure 2 mark(s)
- (c) Mention the life style modification that you would advise to this patient 1 mark(s)
- (d) Add a note on treatment of digoxin over dosage 2 mark(s)
Answer
(a) First-line drugs in congestive cardiac failure
- ACE inhibitors (e.g., Enalapril) / ARBs
- Beta-blockers (e.g., Carvedilol, Bisoprolol, Metoprolol)
- Diuretics (e.g., Furosemide — for symptomatic relief)
- Mineralocorticoid receptor antagonists (e.g., Spironolactone)
(b) Rationale for use in CCF
- ACE inhibitors: Block conversion of angiotensin I to angiotensin II → reduce afterload (vasodilatation) and preload (reduced aldosterone-mediated Na⁺/water retention); also prevent adverse cardiac remodelling — improve survival
- Beta-blockers: Block sympathetic overactivity/chronic catecholamine toxicity to the failing myocardium, reduce heart rate and oxygen demand, prevent arrhythmias, and reduce remodelling — improve long-term survival (started at low dose, up-titrated slowly)
- Diuretics: Reduce preload by promoting Na⁺/water excretion, relieving pulmonary/peripheral congestion — provide symptomatic relief but do not alter mortality
- Spironolactone: Blocks aldosterone-mediated cardiac fibrosis/remodelling and sodium retention — improves survival in moderate-to-severe CCF
(c) Lifestyle modifications
- Salt and fluid restriction
- Weight reduction/regular moderate exercise as tolerated
- Cessation of smoking and alcohol
- Daily weight monitoring to detect fluid retention early
(d) Treatment of digoxin overdose
- Stop digoxin; correct precipitating factors (hypokalaemia, hypomagnesemia, hypoxia)
- Digoxin-specific antibody fragments (Digoxin immune Fab) — definitive treatment for severe toxicity/life-threatening arrhythmias
- Correct hypokalaemia (worsens toxicity) — cautious potassium supplementation
- Treat arrhythmias: Lidocaine or Phenytoin for ventricular arrhythmias; atropine for bradycardia/heart block; avoid quinidine/cardioversion (can worsen toxicity)
- Activated charcoal if recent ingestion