Dyspnea at Rest in a Man With Asthma, Hypertension, and Hyperlipidemia

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A 2-dimensional echocardiogram showed left ventricular ejection fraction of 30% with inferior akinesis.
A 2-dimensional echocardiogram showed left ventricular ejection fraction of 30% with inferior akinesis.

Case

A 55-year-old man who has asthma, hypertension, and hyperlipidemia presents to the emergency department with dyspnea at rest. Electrocardiogram shows inferior Q waves suggestive of a prior myocardial infarction. Physical examination in the emergency department reveals normal heart sounds, laterally displaced point of maximum impulse, and jugular vein distention to the midneck. Auscultation of the lungs reveals very mild expiratory wheezing with mild crackles at the bases. There is bilateral pedal edema.

Laboratory testing shows elevated brain natriuretic peptide levels with 3 serial troponins 6 hours apart of 0.1. Chest radiograph shows some mild pulmonary edema. He is currently taking albuterol/ipratropium nebulizer treatments at home with an inhaled steroid. He takes nifedipine for his blood pressure and atorvastatin 20 mg/d.

A 2-dimensional echocardiogram showed left ventricular ejection fraction of 30% with inferior akinesis. Cardiac catheterization revealed a 99% occluded proximal right coronary artery. He is treated with a drug-eluting stent and started on dual antiplatelet therapy.

During the discharge discussion, the patient expresses concerns about being started on a beta-blocker. He states that he has read online that beta-blockers can make his asthma worse.

Which of the following beta-blockers would be the best choice in this patient?

A. Metoprolol tartrate

B. Metoprolol succinate

C. Propranolol

D. Atenolol

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