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Chapter 6: Acute Decompensated Heart Failure

JP is a 73-year-old man with nonischemic cardiomyopathy (EF 30%-35%) presenting to the emergency department (ED) with an acute HF exacerbation. His vital signs include BP 145/80 mm Hg, heart rate (HR) 92 beats/min, respiratory rate (RR) 23 and O2 sat 96% on 4 L/min of oxygen by nasal cannula (NC). Physical examination reveals 16-cm jugular venous distension (JVD), regular rate and rhythm (RRR), crackles bilaterally, and 3+ bilateral lower extremity edema. He admits to a 20-lb weight gain in the past 3 weeks since his carvedilol dose was increased and reports strict adherence to both dietary restrictions and medications. In the ED, he has already received furosemide 40 mg IV ×1 dose with minimal response in urine output. Pertinent laboratory results include potassium 4.1 mmol/L, BNP 950 pg/mL, BUN 41 mg/dL, and SCr 1.5 mg/dL (baseline). JP’s home medications include enalapril 10 mg twice daily, carvedilol 12.5 mg twice daily, digoxin 0.125 mg/d, and furosemide 40 mg orally twice daily.

Based on the BNP laboratory, JP is experiencing which one of the following? Select all that apply.

a. Active myocardial ischemia

b. Shortness of breath due to a noncardiac etiology

c. Significant volume overload and ventricular wall stretch

d. Renal insufficiency

Answer c is correct. Brain natriuretic peptide (BNP) is released and elevated in the setting of significant volume overload causing stretch of the ventricular wall.

Answer a is incorrect. Common laboratory tests for assessing active myocardial ischemia include creatinine kinase, creatinine kinase-myocardial fraction, and troponin.

Answer b is incorrect. Brain natriuretic peptide (BNP) may be used to rule out other etiologies of shortness of breath due to a noncardiac etiology, in which case the BNP level will be normal. His SOB is due to a heart failure exacerbation with pulmonary edema from cardiac failure which would be a cardiac etiology.

Answer d is incorrect. While BNP may be altered in the setting of renal insufficiency, it is not to the same degree as the level of elevations which occurs in the setting of fluid overload.

JP is a 73-year-old man with nonischemic cardiomyopathy (EF 30%-35%) presenting to the emergency department (ED) with an acute HF exacerbation. His vital signs include BP 145/80 mm Hg, heart rate (HR) 92 beats/min, respiratory rate (RR) 23 and O2 sat 96% on 4 L/min of oxygen by nasal cannula (NC). Physical examination reveals 16-cm jugular venous distension (JVD), regular rate and rhythm (RRR), crackles bilaterally, and 3+ bilateral lower extremity edema. He admits to a 20-lb weight gain in the past 3 weeks since his carvedilol dose was ...

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