VA AM Report 12.19.16-It’s a cardsy, cardsy christmas

Some great pearls today from a patient with heart failure secondary to mitral valve regurgitation from a prior episode of endocarditis. Some cool pearls:

#In cases of aortic regurgitation or mitral regurgitation, a faster heart rate is beneficial as it reduces the amount of regurgitant flow back through the valve. In this gentleman, future Penn cardiology fellow Ashwin Murthy points out that with his elevated left sided filling pressures (has a history of HFpEF), a faster heart rate limits diastolic filling time which was beneficial in this case.

#This patient was having a lot of ectopy and runs of SVT, so he was started on low dose of metoprolol, which dropped his HR into the 60-70s. At this point he began to have poor urine output and stopped diuresing to high doses of bumetanide.

#Contrast with mitral stenosis, where a slower heart rate is better to increase diastolic filling time and increase pre-load

#Another cool Ashwin pearl: remember the EF in mitral regurgitation is misleading, as much of the “ejected” fluid can be regurgitant. Thus a class 1 indication for MVR is a sub-normal EF, i.e. less than 60%.

#Finally, your #LTpearl of the week: in a patient getting high doses of loop diuretics who starts to retain more fluid, start them on thiamine. Thiaminuria can occur with aggressive diuresis and case reports exist showing a wet beri beri-esque disease (high output HF) 2/2 iatrogenic thiamine deficiency. Wild!

Happy holidays nerds, enjoy the break!

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