A 56-year-old man comes to the emergency department due to 5 days of dyspnea. The patient says he wakes up during the night with difficulty breathing that keeps him from going back to sleep. He has never had these symptoms before. Medical history is significant for long-standing hypertension and nonadherence with antihypertensive therapy. The patient developed a deep vein thrombosis 8 years ago after surgery for a tibial fracture and completed 6 months of anticoagulation therapy. He has a 30-pack-year smoking history. Blood pressure is 182/109 mm Hg and pulse is 110/min and regular. Oxygen saturation is 90% on room air. Bibasilar crackles and scattered wheezes are noted on auscultation. Which of the following is the most appropriate next step in management of this patient?

Question

A 56-year-old man comes to the emergency department due to 5 days of dyspnea.  The patient says he wakes up during the night with difficulty breathing that keeps him from going back to sleep.  He has never had these symptoms before.  Medical history is significant for long-standing hypertension and nonadherence with antihypertensive therapy.  The patient developed a deep vein thrombosis 8 years ago after surgery for a tibial fracture and completed 6 months of anticoagulation therapy.  He has a 30-pack-year smoking history.  Blood pressure is 182/109 mm Hg and pulse is 110/min and regular.  Oxygen saturation is 90% on room air.  Bibasilar crackles and scattered wheezes are noted on auscultation.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d325_5a36_bc81_e9fac581228e_MD0003_00 This patient's presentation (dyspnea, orthopnea, paroxysmal nocturnal dyspnea [PND], bibasilar crackles, hypoxemia) is consistent with acute pulmonary edema, most likely due to acute decompensated heart failure (ADHF) from long-standing, uncontrolled hypertension. ADHF is usually due to left ventricular (LV) systolic or diastolic dysfunction with or without other cardiac disease (eg, valvular dysfunction). Initial management of ADHF involves the following: Evaluate clinical stability: Patients with evidence of respiratory failure should receive ventilatory support (eg, noninvasive positive pressure), and patients with evidence of cardiogenic shock (eg, severe hypotension) should receive inotropic support (eg, dobutamine). Improve symptoms: Prompt preload reduction can be achieved with intravenous diuretics (eg, furosemide). Venodilators (eg, nitroglycerin) may be given to help reduce preload; balanced vasodilators (eg, nitroprusside) may be given when afterload reduction is also needed (eg, uncontrolled hypertension). Investigate precipitating factors: ECG and echocardiography help evaluate for precipitating factors, including myocardial ischemia, arrhythmia (eg, atrial fibrillation), and valvular dysfunction (eg, severe mitral regurgitation). This clinically stable patient should receive supplemental oxygen, intravenous diuretics (eg, furosemide) for preload reduction, and a balanced vasodilator (eg, nitroprusside) for preload and afterload reduction. (Choice A) Bronchodilators (eg, albuterol) and systemic corticosteroids are indicated in acute obstructive lung disease. However, this patient's evidence of pulmonary edema (eg, orthopnea, PND, basilar crackles, wheezing caused by interstitial airway edema ["cardiac asthma"]) are more consistent with ADHF. (Choice B) Amiodarone is sometimes used to treat ventricular tachycardia or atrial fibrillation but not heart failure in the absence of specific arrhythmias. (Choice C) Digoxin is occasionally used in long-term management of LV systolic dysfunction (ie, heart failure with reduced ejection fraction [HFrEF]), but it is not useful in the acute setting. (Choice E) Certain beta blockers (eg, metoprolol succinate) reduce long-term mortality in patients with chronic HFrEF. However, they can acutely worsen heart failure symptoms and should not be initiated during an episode of ADHF. Only after adequate diuresis should beta blockers be initiated. (Choice F) In patients with a high likelihood of acute pulmonary embolism, initiating empiric therapeutic anticoagulation is appropriate while awaiting confirmatory test results. However, this patient's progressively worsening dyspnea, PND, and pulmonary edema make ADHF the more likely diagnosis. Educational objective: Pulmonary edema in patients with acute decompensated heart failure should be treated with preload reduction using an intravenous diuretic (eg, furosemide). In patients with uncontrolled hypertension, afterload should also be reduced using a balanced vasodilator (eg, nitroprusside). References: Approaches to decongestion in patients with acute decompensated heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/23299712) HFSA 2010 comprehensive heart failure practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/20610207) 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America (http://www.ncbi.nlm.nih.gov/pubmed/28455343)

A 56-Year-Old Man Comes to the Emergency Department Due to 5