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Chapter 7: Congestive Heart Failure

A 61-year-old man with history of ischemic cardiomyopathy and prior myocardial infarction is admitted to the ICU with symptoms of worsening shortness of breath and lower extremity edema. He has had cardiac resynchronization therapy with an implantable cardiac defibrillator (CRT-ICD) implanted 1 year ago. His home medications include carvedilol 12.5 mg twice a day, lisinopril 5 mg daily, aspirin 81 mg daily, spironolactone 25 mg daily, furosemide 40 mg daily, and atorvastatin 40 mg daily. On examination, he is afebrile, his heart rate (HR) is 60 beats/min, his blood pressure (BP) is 110/59 mmHg, his jugular venous pressure is elevated, his lungs are clear, he has a 3/6 holosystolic murmur with S3, and his lower extremities are cool with +2 pitting edema. Laboratory testing reveals sodium of 124 mmol/L, potassium of 4.6 mmol/L, blood urea nitrogen (BUN) of 51 mg/dL, and creatinine of 1.8 mg/dL. An ECG shows 100% atrioventricular paced rhythm. Which of the following statements is FALSE with respect to this patient’s management?

A. Right heart catheterization may be indicated to assess filling pressures and cardiac output.

B. Hold or decrease the beta-blocker until the patient is hemodynamically stable.

C. Start intravenous furosemide.

D. Start low-dose dopamine to improve renal function.

D. Start low-dose dopamine to improve renal function.

The role of low-dose dopamine in improving renal function is not well established. Neither low-dose dopamine nor low-dose nesiritide improved symptoms or renal function in acute decompensated HF patients presenting with renal dysfunction. Doses of intravenous furosemide (choice C) given either as continuous infusion or 12-hour bolus are equivalent in efficacy in acute decompensated heart failure patients. In patients with evidence of cardiogenic shock or low cardiac output, it is recommended to hold or decrease the beta-blocker (choice B). Right heart catheterization is a useful test in some patients in guiding vasoactive medications including inotropes (choice A). Not listed as an option but something to consider is increasing the pacing rate of the CRT-ICD to provide a higher cardiac output (Heart Rate × Stroke Volume = Cardiac Output).

Which of the following abnormalities is the most important predictor of hospital morbidity and mortality in acute decompensated heart failure in addition to low systolic blood pressure?

A. Serum creatinine

B. Heart rate

C. Serum sodium

D. Hematocrit

A. Serum creatinine

Clinical information obtained at the time of admission can help to predict outcomes during the hospitalization and following discharge. The ADHERE (Acute Decompensated ...

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