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Clinical Crossroads |

A 75-Year-Old Man With Congestive Heart Failure

Gordon Guyatt, MD
JAMA. 1999;281(24):2321-2328. doi:10.1001/jama.281.24.2321.
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DR DELBANCO: Mr C is a 75-year-old retired fisherman who came to the United States from the West Indies more than 10 years ago. He and his wife live in Boston, Mass, with their daughter, who has been an important source of support for him. He has Medicare and supplemental commercial insurance.

In 1988, Mr C developed exertional dyspnea and was diagnosed as having congestive heart failure and chronic obstructive pulmonary disease (COPD), with a forced expiratory volume in 1 second of less than 0.5 L. Chest radiographs showed a large cardiac silhouette, with hyperlucent lung fields and flat diaphragms. Electrocardiogram results showed poor R-wave progression and were consistent with left ventricular hypertrophy and left atrial enlargement. Echocardiogram results showed severe left ventricular dilatation, diffuse hypokinesis, ejection fraction of less than 0.20, and mild right heart dilatation, with 3+ mitral regurgitation and 2+ tricuspid regurgitation. He also had chronic mild renal insufficiency, with a creatinine level of about 221 µmol/L (2.5 mg/dL), and a history of gout, with erosive arthritis, nephrolithiasis, and uric acid stones. There is no known family history of heart disease. Cardiac risk factors include long-standing mild hypertension and 50 pack-years of cigarette smoking, ending in 1988.

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Figure. N-of-1 Randomized Trial
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The patient is randomized to either active treatment or placebo (or alternative treatment). Both physician and patient are blinded to the treatment phase. The arrows represent measurements of the target outcome(s), generally the patient's symptoms. Pairs of treatment periods are repeated until both patient and physician are satisfied that the patient does or does not benefit from the active treatment. The length of each treatment period is determined by the time necessary to reach a steady-state drug level and the estimated treatment duration needed to affect the patient's symptoms. If the treatment effect has a washout period, the target treatment outcome should begin to be monitored after the washout period.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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