Pre-Quiz: Acute Decompensated Heart Failure Pharmacotherapy

A 65-year-old male presents to the emergency department with shortness of breath, fatigue, and peripheral edema. He has a history of hypertension, type 2 diabetes, and chronic heart failure. His vital signs are as follows: blood pressure 95/60 mm Hg, heart rate 95 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 92% on room air. Physical examination reveals jugular venous distension, rales in both lung fields, and 2+ pitting edema in both lower extremities. Laboratory results show a serum creatinine of 1.8 mg/dL and a potassium level of 5.2 mEq/L. The patient is currently on guideline-directed medical therapies, including an ACE inhibitor, a beta-blocker, and a loop diuretic.

Based on the patient’s presentation and hemodynamic parameters, which of the following treatment options is most appropriate for this patient with acute decompensated heart failure (ADHF)?

A 68-year-old male with a history of hypertension, hyperlipidemia, and coronary artery disease presents to the emergency department with shortness of breath, orthopnea, and lower extremity edema. He reports that his symptoms have been worsening over the past week. Vital signs are significant for a blood pressure of 150/90 mmHg, heart rate of 110 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 88% on room air. Physical examination reveals bilateral crackles in the lung bases and 3+ pitting edema in the lower extremities. Laboratory studies show a B-type natriuretic peptide (BNP) level of 1200 pg/mL (normal <100 pg/mL) and a serum creatinine level of 1.5 mg/dL (normal 0.6-1.3 mg/dL).

A 67-year-old male with a history of chronic heart failure (HF) presents to the emergency department with acute decompensated heart failure (ADHF) characterized by dyspnea, peripheral edema, and pulmonary congestion. His past medical history includes hypertension, diabetes, and atrial fibrillation. The patient’s current medications include metoprolol, furosemide, and digoxin. His blood pressure is 190/70 mm Hg, heart rate is 88 bpm, and oxygen saturation is 90% on room air.

Question:

In the management of this patient’s acute decompensated heart failure, which of the following therapeutic interventions would be most appropriate to provide symptomatic relief while preserving hemodynamic stability?

A 68-year-old male with a history of hypertension, hyperlipidemia, and coronary artery disease presents to the emergency department with shortness of breath and bilateral lower extremity edema. His vital signs are as follows: blood pressure 87/40 mmHg, heart rate 120 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 90% on room air. Physical examination reveals bibasilar crackles and jugular venous distension. Chest X-ray shows pulmonary edema. Laboratory results show elevated B-type natriuretic peptide (BNP) levels.

In the management of acute decompensated heart failure, which of the following is an indication for the use of vasoactive agents?

A 60-year-old male with a history of ischemic cardiomyopathy, hypertension, and type 2 diabetes mellitus presents to the emergency department with worsening dyspnea, orthopnea, and lower extremity edema. The patient reports adherence to prescribed medications including an ACE inhibitor, beta-blocker, and aldosterone antagonist. Vital signs are as follows: blood pressure 90/60 mmHg, heart rate 110 bpm, respiratory rate 24 breaths/min, and oxygen saturation 88% on room air. Lab results reveal a B-type natriuretic peptide (BNP) of 1500 pg/mL, serum creatinine 2.5 mg/dL, and potassium 5.2 mmol/L. Echocardiography shows an ejection fraction of 20%. After initial stabilization, the patient is admitted for acute decompensated heart failure.

Which of the following criteria would qualify this patient for advanced heart failure therapy, such as a left ventricular assist device (LVAD) or heart transplantation?