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 responding well to treatment. The second troponin I level is negative. Which of these tests is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Transthoracic echocardiogram should be performed in patients with acute decompensated heart failure (ADHF) of uncertain etiology. In this patient it will allow for confirmation of suspected left ventricular dysfunction (ie, hypertensive cardiomyopathy) and provide an assessment for valvular abnormalities (eg, mitral regurgitation) that may contribute to ADHF. (Choice A) There is no biochemical or significant ECG evidence that myocardial ischemia contributed to this patient's presentation of ADHF. However, if echocardiogram demonstrates left ventricular systolic (rather than only diastolic) dysfunction, stress testing or coronary angiography should be performed to rule out ischemic cardiomyopathy. (Choices B, C, and D) Negative D-dimer testing can rule out acute pulmonary embolism in patients with a low pretest probability of disease. Pulmonary function testing and noncontrast CT scan of the chest can allow for evaluation for other causes of respiratory failure (eg, chronic obstructive pulmonary disease, interstitial lung disease). However, these tests are not indicated in this patient with a clear presentation of ADHF that responded to typical therapy. Educational objective: Transthoracic echocardiogram should be performed in patients with acute decompensated heart failure of uncertain etiology to evaluate for left ventricular and valvular dysfunction. If significant left ventricular systolic dysfunction is present, evaluation for ischemic cardiomyopathy with stress testing or coronary angiography is indicated. References: Management of acute heart failure and the effect of systolic blood pressure on the use of intravenous therapies. (http://www.ncbi.nlm.nih.gov/pubmed/24222833)

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