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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor=( {{YD}} (Reviewed by  {{YD}} and  {{AJL}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Renal
|SubCategory=Renal
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Renal
|SubCategory=Renal
|Prompt=A 68 year old Caucasian male patient with a significant history of alcoholism presented to the emergency department for altered mental status. He was unable to provide further history. Physical examination revealed fetor hepaticus, spider nevi, and gynecomastia. The patient’s abdomen was severely distended with shifting dullness. Following appropriate work-up, the diagnosis of hepatic cirrhosis was made.  Patient was closely followed for further treatment of his condition during hospital admission.  Upon discharge, the patient was prescribed spironolactone for moderate ascites. The patient should be monitored for which of the following electrocardiogram (ECG) finding after initiation of spironolactone?
|Prompt=A 68-year-old man with a significant history of alcoholism presents to the emergency department (ED) with an altered mental status. He is unable to provide further history. His daughter explains that the patient lives alone and has never visited his primary care physician in the 8 years. Physical examination in the ED is remarkable for fetor hepaticus, spider nevi, and gynecomastia. The patient's stomach is severely distended with shifting dullness. Following appropriate work-up, he is diagnosed with hepatic cirrhosis.  At discharge, the patient is prescribed furosemide and spironolactone for his ascites. The patient should be monitored for which of the following electrocardiogram (ECG) changes following spironolactone administration?
|Explanation=Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with severe heart failure and ascites due to hepatic failure.  Randomized Aldactone Evaluation Study (RALES) trial established spironolactone’s clinical benefit on survival in patients with severe heart failure.  Following initiation of spironolactone therapy, serum potassium concentrations should be periodically measured to monitor for hyperkalemia, a common adverse event.   Hyperkalemia is a potential side effect of spironolactone therapy due to inhibition of aldosterone’s physiologic activity in excreting potassium. Hence, spironolactone is described as a “potassium-sparing” diuretic.  A classical ECG finding of hyperkalemia is peaked T waves.
|Explanation=Patients with advanced hepatic cirrhosis are often prescribed diuretics, such as furosemide and spironolactone, to relieve the fluid retention and ascites. [[Spironolactone]] is a competitive aldosterone receptor antagonist and a potassium-sparing diuretic. It is an effective treatment for patients with severe heart failure and [[ascites]] due to [[hepatic failure]].  Following initiation of [[spironolactone]] therapy, serum potassium concentrations should be periodically measured to monitor for [[hyperkalemia]]. [[Hyperkalemia]] is a potential adverse effect of [[spironolactone]] therapy that results from the inhibition of the physiologic activity of aldosterone with spironolactone administration. Peaked T waves are typical ECG findings that are suggestive of hyperkalemia.  
 
Educational Objective:
Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with hepatic failure and ascites. Hyperkalemia is a common side effect of spironolactone therapy that manifests as peaked T waves on ECG.
 
References:
Nappi JM, Sieg A.  Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure.  Vasc Health Risk Manag.  2011;7:353-363.


Biecker E.  Diagnosis and therapy of ascites in liver cirrhosis.  World J Gastroenterol.  2011;17(10):1237-1248.
|AnswerA=Two independent rhythms of P and QRS complexes
|AnswerA=Two independent rhythms of P and QRS complexes
|AnswerAExp=Third degree AV block is not commonly associated with spironolactone therapy. AV blockade is commonly seen in patients receiving beta blockers and calcium channel blockers.
|AnswerAExp=Third degree AV block is not classically associated with [[spironolactone]] therapy. AV blockades are often observed among patients administered beta blockers and calcium channel blockers.
|AnswerB=“Saw tooth” appearance
|AnswerB=Saw tooth appearance
|AnswerBExp=“Saw tooth” appearance is the characteristic description of atrial flutter. Spironolactone is not commonly associated with atrial flutter.
|AnswerBExp=A saw tooth appearance is a characteristic electrocardiographic description of [[atrial flutter]]. Administration of [[spironolactone]] is not commonly associated with [[atrial flutter]].
|AnswerC=Peaked T waves
|AnswerC=Peaked T waves
|AnswerCExp=Peaked T waves on ECG is characteristic of hyperkalemia, a common side effect of spironolactone therapy.
|AnswerCExp=Peaked T waves on ECG are characteristic of [[hyperkalemia]], a common adverse effect associated with administration of [[spironolactone]] (potassium-sparing diuretic).  
|AnswerD=ST-segment elevation in leads I and aVL
|AnswerD=ST-segment elevation in leads I and aVL
|AnswerDExp=ST-segment elevation is seen in myocardial infarction
|AnswerDExp=ST-segment elevation is not typically associated with spironolactone administration
|AnswerE=Prolonged PR interval
|AnswerE=Prolonged PR interval
|AnswerEExp=Prolonged PR interval is characteristic of first degree AV block. Spironolactone does not commonly cause first degree AV blockade.
|AnswerEExp=Prolonged PR interval is characteristic of first degree AV block. Spironolactone is not classically associated with first degree AV blockade.
|EducationalObjectives=[[Spironolactone]] is a competitive aldosterone receptor antagonist and a potassium-sparing diuretic. It is an effective treatment for patients with advanced [[hepatic cirrhosis]] with [[ascites]]. [[Hyperkalemia]] is a common adverse effect of spironolactone therapy. Hyperkalemia typically manifests as peaked T waves on ECG.
|References=Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol. 2011;17(10):1237-1248.<br>
Nappi JM, Sieg A. Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure. Vasc Health Risk Manag. 2011;7:353-363.<br>
First Aid 2014 page 548
|RightAnswer=C
|RightAnswer=C
|Approved=No
|WBRKeyword=Spironolactone, Potassium sparing diuretic, Diuretics, Electrocardiography, ECG, EKG, Peaked t waves, Cirrhosis, Hepatic failure, Ascites, Furosemide, Alcoholic liver disease, Adverse effect, Side effect, Monitoring
|Approved=Yes
}}
}}

Latest revision as of 00:21, 28 October 2020
Author [[PageAuthor::( Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D. and Alison Leibowitz [1])]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Renal
Prompt [[Prompt::A 68-year-old man with a significant history of alcoholism presents to the emergency department (ED) with an altered mental status. He is unable to provide further history. His daughter explains that the patient lives alone and has never visited his primary care physician in the 8 years. Physical examination in the ED is remarkable for fetor hepaticus, spider nevi, and gynecomastia. The patient's stomach is severely distended with shifting dullness. Following appropriate work-up, he is diagnosed with hepatic cirrhosis. At discharge, the patient is prescribed furosemide and spironolactone for his ascites. The patient should be monitored for which of the following electrocardiogram (ECG) changes following spironolactone administration?]]
Answer A AnswerA::Two independent rhythms of P and QRS complexes
Answer A Explanation [[AnswerAExp::Third degree AV block is not classically associated with spironolactone therapy. AV blockades are often observed among patients administered beta blockers and calcium channel blockers.]]
Answer B AnswerB::Saw tooth appearance
Answer B Explanation [[AnswerBExp::A saw tooth appearance is a characteristic electrocardiographic description of atrial flutter. Administration of spironolactone is not commonly associated with atrial flutter.]]
Answer C AnswerC::Peaked T waves
Answer C Explanation [[AnswerCExp::Peaked T waves on ECG are characteristic of hyperkalemia, a common adverse effect associated with administration of spironolactone (potassium-sparing diuretic).]]
Answer D AnswerD::ST-segment elevation in leads I and aVL
Answer D Explanation AnswerDExp::ST-segment elevation is not typically associated with spironolactone administration
Answer E AnswerE::Prolonged PR interval
Answer E Explanation AnswerEExp::Prolonged PR interval is characteristic of first degree AV block. Spironolactone is not classically associated with first degree AV blockade.
Right Answer RightAnswer::C
Explanation [[Explanation::Patients with advanced hepatic cirrhosis are often prescribed diuretics, such as furosemide and spironolactone, to relieve the fluid retention and ascites. Spironolactone is a competitive aldosterone receptor antagonist and a potassium-sparing diuretic. It is an effective treatment for patients with severe heart failure and ascites due to hepatic failure. Following initiation of spironolactone therapy, serum potassium concentrations should be periodically measured to monitor for hyperkalemia. Hyperkalemia is a potential adverse effect of spironolactone therapy that results from the inhibition of the physiologic activity of aldosterone with spironolactone administration. Peaked T waves are typical ECG findings that are suggestive of hyperkalemia.

Educational Objective: Spironolactone is a competitive aldosterone receptor antagonist and a potassium-sparing diuretic. It is an effective treatment for patients with advanced hepatic cirrhosis with ascites. Hyperkalemia is a common adverse effect of spironolactone therapy. Hyperkalemia typically manifests as peaked T waves on ECG.
References: Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol. 2011;17(10):1237-1248.
Nappi JM, Sieg A. Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure. Vasc Health Risk Manag. 2011;7:353-363.
First Aid 2014 page 548]]

Approved Approved::Yes
Keyword WBRKeyword::Spironolactone, WBRKeyword::Potassium sparing diuretic, WBRKeyword::Diuretics, WBRKeyword::Electrocardiography, WBRKeyword::ECG, WBRKeyword::EKG, WBRKeyword::Peaked t waves, WBRKeyword::Cirrhosis, WBRKeyword::Hepatic failure, WBRKeyword::Ascites, WBRKeyword::Furosemide, WBRKeyword::Alcoholic liver disease, WBRKeyword::Adverse effect, WBRKeyword::Side effect, WBRKeyword::Monitoring
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