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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Identify the signs and symptoms of acute decompensated heart failure (ADHF).

  • Classify a patient into the appropriate hemodynamic subset based on symptoms and clinical presentation.

  • List goals of therapy for treating ADHF.

  • Develop a pharmacotherapeutic plan for treating a patient with ADHF in the hemodynamic subset presented.

  • Outline a monitoring plan for treating a patient with ADHF in the hospital.

PATIENT PRESENTATION

Chief Complaint

“I can no longer lie down flat because I can’t breathe and I’ve gained 5 pounds in 3 days.”

HPI

Bizzy Fuller is a 64-year-old woman with a history of ischemic cardiomyopathy with last known EF 25% (ECHO 1.5 years ago). She presents to the emergency department with approximately 2–3 days of increasing shortness of breath, and she reports having gained approximately 5 lb over the past 3 days. She also notes that she has had increasing leg swelling over the same time period. Over the past week, the patient has noted increasing bloating in her abdomen and has felt slightly nauseated. She has had problems with diarrhea and constipation since her cholecystectomy several months ago. She has been on a fiber supplement, from which she has derived some benefit. She states that she had been on torsemide many years ago but for an unknown reason was switched to furosemide.

PMH

CAD (status postmyocardial infarction × 2 in early 2000s; CABG in 2000, PCI in May 2002)

Paroxysmal ventricular tachycardia (status post-ICD placement in 2011)

Obstructive sleep apnea

Diabetes mellitus type 2

Depression

Dyslipidemia

Mild osteoarthritis

GERD

Seasonal allergies

FH

Both her mother and father died of MI in their 60s.

SH

Patient is a happily married, retired school teacher and is fully functional with ADLs. She is an occasional alcohol drinker (two to three drinks per week) and has a 30 pack-year history, but quit smoking approximately 12 years ago.

Meds

Fexofenadine 60 mg orally BID

Insulin detemir 40 units subcutaneously at bedtime

Insulin aspart 7 units subcutaneously before each meal

Aspirin 81 mg orally once daily

Carvedilol 12.5 mg orally BID

Duloxetine 30 mg orally once daily

Fluticasone nasal spray 50 mcg one spray BID

Lasix 80 mg orally BID

Valsartan 80 mg orally twice ...

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