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Chapter 2. Acute Decompensated Heart Failure

RF is a 62-year-old man with nonischemic cardiomyopathy (left ventricular ejection fraction [LVEF] 30%) presenting to the emergency department (ED) with worsening dyspnea consistent with acute decompensated heart failure (ADHF). His vital signs include a BP 155/90 mm Hg and heart rate (HR) 85 beats per minute (bpm). Physical examination is significant for jugular venous distension (JVD), crackles bilaterally at the bases, and 2+ bilateral lower extremity edema. He admits to a 12-lb weight gain in the past 2 weeks. Pertinent laboratory results include potassium 3.9 mmol/L, BNP 1550 pg/mL, and serum creatinine (SCr) 1.3 mg/dL (baseline). RF's home medications include lisinopril 10 mg daily, carvedilol 25 mg twice daily, and furosemide 40 mg orally twice daily. Which of the following therapies may be used for the relief of RF's congestive symptoms? Please select all that apply.

a. Bumetanide

b. Nitroglycerin

c. Dopamine

d. Dobutamine

Answers a and b are correct. Loop diuretics (Answer A) are first-line therapy for patients with ADHF and congestive symptoms. Nitroglycerin (Answer B) may also be considered (in conjunction with loop diuretics) given this patient's elevated BP on presentation.

Answers c and d are incorrect. Dopamine (Answer C) is incorrect, as this agent may further increase BP. Additionally, there is no evidence of low cardiac output (CO), thus an agent with inotropic activity is not necessary. For this latter reason, dobutamine (Answer D) is also incorrect.

RF is a 62-year-old man with nonischemic cardiomyopathy (left ventricular ejection fraction [LVEF] 30%) presenting to the emergency department (ED) with worsening dyspnea consistent with acute decompensated heart failure (ADHF). His vital signs include a BP 155/90 mm Hg and heart rate (HR) 85 beats per minute (bpm). Physical examination is significant for jugular venous distension (JVD), crackles bilaterally at the bases, and 2+ bilateral lower extremity edema. He admits to a 12-lb weight gain in the past 2 weeks. Pertinent laboratory results include potassium 3.9 mmol/L, BNP 1550 pg/mL, and serum creatinine (SCr) 1.3 mg/dL (baseline). RF's home medications include lisinopril 10 mg daily, carvedilol 25 mg twice daily, and furosemide 40 mg orally twice daily. Over the course of several days, the patient's condition worsens despite the agents bumetanide and nitroglycerin. His vitals include a BP 92/60 mm Hg and a HR 92 bpm, and his SCr has increased to 2.2 mg/dL. After failing to meet urine output goals, the team elects to insert a pulmonary artery catheter, which reveals the following: pulmonary capillary wedge pressure (PCWP) 24 mm Hg, cardiac index (CI) 1.5 L/min/m2, and systemic vascular resistance (SVR) 1090 dyne·sec·cm-5. Which of the following hemodynamic parameters is an ...

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