A 60-year-old man is brought to the emergency department due to acute-onset shortness of breath. His past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes mellitus. His current medications include hydrochlorothiazide, insulin glargine, atorvastatin, aspirin, and a daily multivitamin. Temperature is 36.7 C (98 F), blood pressure is 128/72 mm Hg, pulse is 116/min, and respirations are 28/min. Physical examination shows an anxious-appearing, diaphoretic man. Jugular venous pulsations are noted up to the angle of the jaw. The heart sounds are regular, and an S3 gallop and faint holosystolic murmur are heard over the cardiac apex. Lung examination shows crackles to the mid-lung level bilaterally. He has pitting edema in both lower extremities. Which of the following is the best initial approach to improving this patient's symptoms?
A)Blocking sympathetic activity
B)Decreasing cardiac preload
C)Decreasing heart rate
D)Improving myocardial contractility
E)Increasing coronary perfusion pressure

Question

A 60-year-old man is brought to the emergency department due to acute-onset shortness of breath.  His past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes mellitus.  His current medications include hydrochlorothiazide, insulin glargine, atorvastatin, aspirin, and a daily multivitamin.  Temperature is 36.7 C (98 F), blood pressure is 128/72 mm Hg, pulse is 116/min, and respirations are 28/min.  Physical examination shows an anxious-appearing, diaphoretic man.  Jugular venous pulsations are noted up to the angle of the jaw.  The heart sounds are regular, and an S3 gallop and faint holosystolic murmur are heard over the cardiac apex.  Lung examination shows crackles to the mid-lung level bilaterally.  He has pitting edema in both lower extremities.  Which of the following is the best initial approach to improving this patient's symptoms?
A)Blocking sympathetic activity
B)Decreasing cardiac preload
C)Decreasing heart rate
D)Improving myocardial contractility
E)Increasing coronary perfusion pressure

Quizplus · Accepted Answer

Explanation: 11ec2b69_c10c_6c78_8f63_d753e54d8485_MD0005_00 This patient's presentation - dyspnea, jugular venous distension, bilateral lung crackles, and lower-extremity edema - is consistent with acute decompensated heart failure (ADHF). The presence of an S3 gallop and holosystolic murmur is suggestive of dilated cardiomyopathy with functional mitral regurgitation. ADHF most commonly occurs due to left ventricular (LV) systolic and/or diastolic dysfunction, with or without coexisting valvular or coronary heart disease. A sudden increase in pulmonary capillary wedge pressure (along with left atrial and ventricular filling pressures or LV preload) leads to accumulation of fluid in pulmonary interstitial and alveolar spaces. The goal of initial management in ADHF is to ensure hemodynamic stability, maintain adequate ventilation and oxygenation, and provide rapid symptomatic relief, along with ongoing evaluation to identify the predisposing and/or precipitating causes. An urgent pulse oximetry, chest radiograph, and electrocardiogram (ECG) should be obtained. The most appropriate next step in improving symptoms of ADHF is to reduce the cardiac preload with diuretics and intravenous vasodilators (eg, nitroglycerine, nitroprusside, nesiritide) in selected patients without hypotension. (Choice A) Intravenous morphine sulfate reduces central sympathetic outflow, causing venous and arteriolar dilation and potential drop in cardiac preload. However, data on its safety and efficacy are quite limited and current guidelines do not recommend the use of morphine in ADHF. (Choice C) Beta blockers are recommended in the long-term management of patients with heart failure due to systolic dysfunction. But tachycardia in patients with ADHF due to systolic dysfunction is a response/sign of respiratory distress, and attempts to control heart rate with beta blockers can further worsen symptoms. Adequate heart rate control, control of hypertension, and diuretic therapy are recommended in patients with heart failure with preserved ejection fraction (or diastolic heart failure). (Choice D) Improving myocardial contractility with intravenous inotropic agents (eg, dobutamine, milrinone) is recommended only in patients with severe LV dysfunction and low cardiac output causing poor peripheral perfusion or end-organ dysfunction. It is also used in similar patients with inadequate response to diuretic therapy. Routine use of inotropic agents has been found to be deleterious, with an increased incidence of hypotension, arrhythmias, and in-hospital mortality. (Choice E) Coronary revascularization to increase coronary perfusion pressure is indicated in patients with myocardial ischemia as the precipitating factor for ADHF. However, the initial approach should be to reduce cardiac preload for rapid symptomatic improvement while the patient is being evaluated for the presence of myocardial ischemia. Educational objective: Patients with acute decompensated heart failure should be managed initially with diuretics (and/or intravenous vasodilators) to reduce cardiac preload for rapid symptom relief. Evaluation should be initiated to identify the predisposing and/or precipitating causes. 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 American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23741058)

A 60-Year-Old Man Is Brought to the Emergency Department Due