A 68-year-old man is admitted to the critical care unit for acute decompensated heart failure with reduced ejection fraction (HFrEF). He requires bilevel positive airway pressure (BiPAP) for respiratory distress and is receiving a continuous norepinephrine infusion via a central venous catheter. Despite receiving a 20 mg IV bolus of furosemide followed by a continuous infusion at 10 mg/hour for the past 24 hours, he remains significantly fluid overloaded with persistent crackles, jugular venous distension, and a 2 kg weight gain since admission. His blood pressure is 105/60 mmHg, heart rate 92 bpm, and oxygen saturation 90% on BiPAP. Labs show a serum creatinine of 1.8 mg/dL (baseline 1.2 mg/dL) and a potassium of 4.1 mEq/L. He can swallow medications and has no contraindications to oral therapy. Given the patient’s persistent signs of congestion despite the current diuretic regimen, which of the following is the most appropriate next step in pharmacotherapy to achieve euvolemia?

A 62-year-old man (weight 70 kg) with HFrEF is admitted for acute decompensated heart failure. He has a central line infusing norepinephrine at 0.05 mcg/kg/min to maintain MAP > 65 mmHg. He is receiving a continuous furosemide infusion at 0.3 mg/kg/hour (≈ 21 mg/h). Over the past 24 hours, his urine output has averaged 150 mL/h, pulmonary crackles have resolved, and his CVP has fallen from 18 to 10 mmHg. His serum creatinine has risen from 1.0 mg/dL to 1.4 mg/dL and BUN from 25 mg/dL to 38 mg/dL. Given these findings, which is the MOST appropriate next step in managing his diuresis?

A 65-year-old male is admitted to the intensive care unit with acute decompensated heart failure (ADHF). He is mechanically ventilated and requires continuous vasopressor support to maintain hemodynamic stability. His left ventricular ejection fraction (LVEF) is 25%. His history includes ischemic cardiomyopathy and persistent atrial fibrillation, previously managed with metoprolol and apixaban. During this admission, he has had non-sustained ventricular tachycardia and heart rates between 100–120 bpm. He is undergoing optimization of guideline-directed medical therapy (GDMT) for heart failure. What is the MOST appropriate timing recommendation for prophylactic implantable cardioverter-defibrillator (ICD) placement?

A 62-year-old man (weight 70 kg) is admitted to the medical intensive care unit with acute decompensated heart failure and cardiogenic shock. He is intubated on assist–control ventilation and has a central venous catheter for infusions of norepinephrine at 0.2 mcg/kg/min and vasopressin at 0.04 units/min to maintain a mean arterial pressure above 65 mmHg. Despite an initial trial of a continuous furosemide infusion at 20 mg/hour and dobutamine at 5 mcg/kg/min, his urine output has decreased to <20 mL/hour over the last 4 hours. An arterial blood gas shows pH 7.18, PaCO2 48 mmHg, PaO2 90 mmHg, and bicarbonate 18 mEq/L. His serum lactate is 5.2 mmol/L. Which of the following is the most appropriate next intervention for this patient?

A 62-year-old, 75-kg male with acute decompensated heart failure complicated by cardiogenic shock is admitted to the ICU. He is intubated and on assist-control ventilation, receiving continuous infusions of norepinephrine at 0.1 mcg/kg/min and dobutamine at 5 mcg/kg/min for the past 6 hours via a central venous catheter. An arterial line is in place for continuous blood pressure monitoring. Current vital signs: HR 105 bpm, BP 98/62 mm Hg (MAP 74 mm Hg), RR 18 breaths/min, SpO₂ 96%. Recent labs: lactate 3.8 mmol/L (down from 5.2 mmol/L 6 hours ago), SCr 1.8 mg/dL (baseline 1.2), urine output 25 mL/hr over the last 2 hours. Pulmonary artery catheter data: CI 2.0 L/min/m², PCWP 20 mm Hg, SvO₂ 60%. Given these hemodynamics and signs of ongoing hypoperfusion, which of the following is the MOST appropriate immediate adjustment?

A 62-year-old, 70-kg male is admitted to the critical care unit intubated and on assist-control mechanical ventilation with FiO₂ 0.6. He is receiving a norepinephrine infusion at 0.1 mcg/kg/min via a central venous catheter for hypotension. He presents with acute decompensated heart failure complicated by severe right ventricular (RV) dysfunction and pulmonary hypertension. His blood pressure is 88/52 mmHg and heart rate is 115 bpm. Pulmonary artery catheterization shows: CVP 20 mmHg, PA pressure 60/30 mmHg (mean 40 mmHg), PCWP 12 mmHg, and cardiac index 1.8 L/min/m². Urine output has been 15 mL/hr over the past 4 hours. His creatinine is 1.8 mg/dL (baseline 1.0 mg/dL) and potassium is 3.2 mEq/L. Which of the following is the most appropriate next step?

A 62-year-old man (weight 80 kg) is admitted to the ICU for acute decompensated heart failure with severe pulmonary edema. He reports non-adherence to his home furosemide (80 mg PO twice daily) for the past week. On exam: BP 165/98 mmHg, HR 105 bpm, RR 28 breaths/min, SpO₂ 92% on NIPPV; bilateral crackles, jugular venous distension, and 3+ peripheral edema. Laboratory values: BUN 28 mg/dL, serum creatinine 1.2 mg/dL (baseline 1.0 mg/dL), Na⁺ 138 mmol/L, K⁺ 4.2 mmol/L, BNP 2500 pg/mL. He is warm and perfused but hypertensive with volume overload. Which of the following is the most appropriate initial pharmacologic intervention?

A 72-year-old male is admitted to the critical care unit with acute decompensated heart failure (ADHF), presenting with severe dyspnea, orthopnea, and bilateral crackles. He is currently on noninvasive positive-pressure ventilation (NIPPV) and has a central venous catheter in place. His blood pressure is 130/80 mm Hg, heart rate 98 bpm, and oxygen saturation 92% on NIPPV. Labs show a serum creatinine of 1.3 mg/dL (baseline 1.0 mg/dL) and potassium 4.1 mEq/L. He reports adherence to his home regimen of furosemide 40 mg orally twice daily. Chest X-ray demonstrates significant pulmonary edema. Considering his presentation and chronic oral loop diuretic use, which of the following is the MOST appropriate initial intravenous loop diuretic strategy?

A 65-year-old man is admitted to the critical care unit with acute decompensated heart failure and cardiogenic shock. He is intubated, on mechanical ventilation, and receiving a norepinephrine infusion via a central line. Despite initial therapy, his hemodynamics remain unstable with a cardiac index (CI) of 1.8 L/min/m², mean arterial pressure (MAP) of 58 mmHg, and pulmonary capillary wedge pressure (PCWP) of 28 mmHg. Echocardiography reveals severe biventricular dysfunction. His body surface area (BSA) is 1.9 m². Based on this patient’s hemodynamic profile, which of the following mechanical circulatory support devices is most appropriate to initiate?

A 68-year-old, 80 kg man is admitted to the ICU with acute decompensated heart failure complicated by cardiogenic shock. He is intubated and mechanically ventilated. His past medical history includes HFrEF on metoprolol succinate 100 mg daily. Vital signs: BP 82/50 mmHg, HR 115 bpm, SpO₂ 94% on 50% FiO₂. Examination reveals cool extremities and crackles. Labs show BNP elevated, troponin moderately elevated, creatinine 1.8 mg/dL (baseline 1.0). Hemodynamics by pulmonary artery catheter: CVP 12 mmHg, PCWP 25 mmHg, cardiac index 1.8 L/min/m², SVR 1,500 dyn·sec·cm⁻⁵. He is on norepinephrine 0.05 µg/kg/min. Which inotropic agent is most appropriate to initiate?