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.
Which of the following is the most appropriate next step in management of this patient?

Question

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.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Acute decompensated heart failure (ADHF) results from a critical elevation in intracardiac filling pressures that most commonly occurs due to left ventricular (LV) systolic and/or diastolic dysfunction (eg, coronary ischemia, hypertensive cardiomyopathy). Other causes include valvular disease and marked elevations in preload (eg, excessive volume resuscitation) or afterload (eg, severe hypertension). This patient with chronic hypertension, possible medication nonadherence (eg, refusing statins and vaccinations), ECG evidence of LV hypertrophy (ie, increased voltage in the precordial leads), and several weeks of cough likely has chronic LV dysfunction due to hypertension. She has experienced gradually increasing LV filling pressures that reached a critical point, resulting in ADHF and pulmonary edema (bilateral crackles, vascular congestion on chest x-ray, tachypnea, hypoxia). Jugular venous distension is usually present but lower extremity edema may be absent, especially in patients without chronic heart failure. Early therapeutic goals include hemodynamic stabilization, improved oxygenation (ie, with supplemental oxygen or positive pressure ventilation), and optimization of volume status. Intravenous diuretics (eg, furosemide) are an important part of initial therapy as they reduce intravascular volume, lower intracardiac filling pressures, and improve pulmonary edema. (Choice A) This patient is without fever, purulent sputum production, or focal consolidation on chest x-ray to suggest respiratory failure due to pulmonary infection; intravenous antibiotics are not indicated. (Choice C) Glucocorticoids (eg, methylprednisolone) are indicated for an exacerbation of chronic obstructive pulmonary disease; however, this patient's bilateral crackles on lung examination, evidence of pulmonary edema on chest x-ray, and lack of tobacco use make ADHF more likely. (Choice D) Beta blockers (eg, metoprolol) are important in the management of chronic heart failure due to LV systolic dysfunction. They are also used in certain patients with tachyarrhythmias or ST-elevation myocardial infarction. However, they are usually contraindicated in ADHF due to the negative inotropy and chronotropy causing a potential worsening of pulmonary edema. (Choice E) Intravenous thrombolytic (eg, alteplase) therapy is indicated in patients with hypotension (ie, systolic blood pressure <90 mm Hg) or shock due to acute pulmonary embolism. This patient is not hypotensive and the several weeks of cough, marked pulmonary edema on chest x-ray, and absence of chest pain make ADHF more likely. Educational objective: Acute decompensated heart failure results from a critical elevation in intracardiac filling pressures, often due to left ventricular dysfunction, and leads to pulmonary edema. Intravenous diuretics (eg, furosemide) lower intracardiac filling pressures and improve pulmonary edema, and are an important part of initial therapy. References: HFSA 2010 comprehensive heart failure practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/20610207) 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)

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