Clinical Scenario:
A 3-year-old boy presents with progressive breathlessness and poor appetite for 3 weeks. He has puffiness of the face and abdominal distension. On examination: HR 150/min, RR 44/min, BP 90/60 mmHg, and bilateral pedal edema. Auscultation reveals a soft S3 gallop and mild hepatomegaly. CXR shows cardiomegaly with a cardiothoracic ratio of 0.65. Echocardiography shows a dilated left ventricle with global hypokinesia and an ejection fraction of 30%. Coronary origins are normal.
What is the most appropriate initial pharmacological management?
A. ACE inhibitor and diuretic
B. Beta-blocker alone
C. Digoxin alone
D. Prostaglandin infusion
E. Sildenafil
Correct answer & Explanation:
Correct Answer: A — ACE inhibitor and diuretic
Explanation:
Why A is correct: Standard first-line therapy for chronic heart failure due to dilated cardiomyopathy is afterload reduction (ACE inhibitor) combined with a diuretic for symptomatic congestion. This combination improves symptoms and cardiac remodeling in stable, compensated heart failure.
Why others are wrong:
- B — Beta-blockers are added later, once the patient is stable on ACE inhibitors/diuretics, not started alone as initial therapy.
- C — Digoxin may be added for symptom control but is not first-line/initial monotherapy.
- D — Prostaglandin is for duct-dependent congenital heart disease, irrelevant here.
- E — Sildenafil treats pulmonary hypertension, not the primary problem in dilated cardiomyopathy.
