Medical Management of an 82-Year-Old Patient With a History of Coronary Disease and Ischemic Cardiomyopathy

Access related cases on pharmacology and earn CME/CE credit by taking The Essentials of Cardiovascular Care for Older Adults (ECCOA).

Case Presentation

You are asked to consult on an 82-year-old artist who has been hospitalized for a hip fracture. She lives independently with her husband and is independent in all of her activities of daily living (ADLs) and instrumental ADLs prior to this event. She has a long-standing history of coronary disease and an ischemic cardiomyopathy with New York Heart Association class III heart failure at baseline. Her medications include lisinopril 10 mg once daily, metoprolol 25 mg twice daily, furosemide 20 mg once daily, aspirin 81 mg once daily, pravastatin 40 mg qd once daily, digoxin 0.125 ng/L once daily, and extra strength Tylenol for the pain.

On exam, she is confused and confabulating with visual hallucinations. She is picking at the sheets and seems agitated. Vital signs show blood pressure  90/60 mm Hg, heart rate 110 bpm, irregularly irregular rhythm, respiration 20 breaths/minute, weight 58 kg, and oxygen saturation 98% on 2 L nasal cannula. Skin turgor is poor, jugular venous pressure is flat, lungs are clear. Cardiac exam reveals diffuse point of maximal impulse; irregularly irregular rhythm; S1, S2, S3 are heard; abdomen is benign; extremities show no edema; and her left foot is externally rotated. 

The orthopedic surgeon wants to pin her hip and has asked you to evaluate her risk for surgery. Her ECG shows atrial fibrillation at 114 bpm, anterolateral Q waves, nonspecific intraventricular conduction delay of 132 ms, and inferior ST depressions. Compared to an ECG 2 months ago, the atrial fibrillation and widened QRS are new. Labs are remarkable for sodium 128 mEq/L, potassium 5.3 mEq/L, blood urea nitrogen 64 mg/dl, creatinine 2.8 mg/dl (baseline 1.3), normal complete blood cell count, negative cardiac enzymes, and B-type natriuretic peptide 130 pg/ml.

All of the following medications should be adjusted or held in the setting of acute renal failure, EXCEPT:

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