A 70-year-old woman is brought to the emergency department by her son for evaluation of shortness of breath. She has had a sensation of choking since last night. According to her son, for the past several weeks she has had a dry cough at night and has been taking over-the-counter cough drops. The patient has had no chest pain, palpitations, back pain, abdominal symptoms, or lightheadedness. She has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. She has been refusing statin therapy, as she heard statins cause multiple side effects. The patient has also refused flu vaccinations over the last several years. Her only hospital admission occurred 6 years ago when she underwent a spinal fusion for lower back pain. She does not use tobacco, alcohol, or illicit drugs. Family history is not significant. Temperature is 36.1 C (97 F), blood pressure is 171/102 mm Hg, pulse is 92/min, and respirations are 34/min. Pulse oximetry is 85% on room air. BMI is 29 kg/m². Bilateral crackles are heard on lung examination. There are no heart murmurs. ECG shows normal sinus rhythm, increased voltage in the precordial leads, and T-wave inversion in leads V5 and V6. Chest x-ray is shown in the exhibit. Oxygen is administered via 100% nonrebreather facemask. The patient is placed on noninvasive positive pressure ventilation but still appears somewhat uncomfortable. Laboratory results are as follows: The first troponin I level is negative. Repeat blood pressure is 176/105 mm Hg, pulse is 82/min, and respirations are 24/min. Oxygen saturation is 94%. What is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: The addition of an intravenous vasodilator is recommended in patients with acute decompensated heart failure (ADHF) who have an inadequate response to initial diuretic therapy. Nitroglycerin is most commonly used; as primarily a venous dilator, it leads to a rapid decrease in cardiac preload, resulting in reduced intracardiac filling pressures and improvement in pulmonary edema. Nitroprusside is less commonly used due to the risk of adverse effects (eg, cyanide toxicity, severe hypotension); it decreases intracardiac filling pressures through balanced vasodilation and reductions in both cardiac preload and afterload. Because intravenous vasodilator therapy often results in rapid improvement of acutely symptomatic pulmonary edema, it is indicated right away (prior to or instead of intravenous diuretics) in patients with "flash" pulmonary edema due to severe hypertension (>180/120 mm Hg) (ie, hypertensive emergency). (Choice A) Digoxin is a positive inotropic agent used in some patients with chronic heart failure due to left ventricular (LV) systolic dysfunction. However, it has no role in the management of ADHF. (Choice B) Pulmonary edema due to atrial fibrillation with rapid ventricular response is one ADHF scenario where metoprolol may actually provide benefit (by increasing markedly low ventricular filling times); however, in this patient with normal heart rate and sinus rhythm on ECG, metoprolol is likely to worsen pulmonary edema. (Choice C) Milrinone is a selective phosphodiesterase-3 inhibitor that causes positive inotropy as well as reductions in preload and afterload. It can be useful for ADHF due to LV systolic dysfunction; however, it is associated with increased risk of hypotension and atrial or ventricular arrhythmia, and is typically reserved for severe ADHF that is refractory to other management. (Choice E) Intravenous unfractionated heparin is indicated for acute myocardial infarction, which can lead to ADHF. However, there is currently no evidence of acute myocardial infarction in this patient with no chest pain, no ST elevation on ECG, and a negative initial serum troponin. Educational objective: Intravenous vasodilators (eg, nitroglycerin) reduce intracardiac filling pressures and are recommended in patients with acute decompensated heart failure who have an inadequate response to initial diuretic therapy. In addition, they are indicated as initial therapy (prior to or instead of intravenous diuretics) in patients with "flash" pulmonary edema due to severe hypertension. References: 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23741058) HFSA 2010 comprehensive heart failure practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/20610207)

A 70-Year-Old Woman Is Brought to the Emergency Department by Her