Credit: Original article published here.
The following question refers to Section 9.5 of the2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & CardioNerds InternHirsh Elhence, answered first by Duke University cardiology fellow and CardioNerds FIT AmbassadorDr. Aman Kansal, and then by expert facultyDr. Javed Butler.
Dr. Butler is an advanced heart failure and transplant cardiologist, President of the Baylor Scott and White Research Institute, Senior Vice President for the Baylor Scott and White Health, and Distinguished Professor of Medicine at the University of Mississippi.
TheDecipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failureseries was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds CofoundersDr. Amit GoyalandDr. Dan Ambinder, with mentorship fromDr. Anu Lala,Dr. Robert Mentz, andDr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Mrs. Hart is a 70-year-old woman hospitalized for a 2-week course of progressive exertional dyspnea, increasing peripheral edema, and mental status changes. She has a history of coronary artery disease, hypertension, and heart failure for which she takes aspirin, furosemide, carvedilol, lisinopril, and spironolactone. On physical exam, the patient is afebrile, BP is 80/60 mmHg, heart rate is 120 bpm, and respiratory rate is 28 breaths/min with O2 saturation of 92% breathing room air. She is sitting upright and is confused. Jugular venous pulsations are elevated. Cardiac exam reveals an S3 gallop. There is ascites and significant flank edema on abdominal exam. Her lower extremities have 2+ pitting edema to her knees and are cool to touch. Her labs are significant for an elevated serum Creatinine of 3.0 from a baseline of 1.0 mg/dL, lactate of 3.0 mmol/L, and liver enzyme elevation in the 300s U/L.
Which of the following is the most appropriate initial treatment?
A
Increase carvedilol
B
Start dobutamine
C
Increase lisinopril
D
Start nitroprusside
Explanation
The Correct answer is B – start dobutamine.
This patient with progressive congestive symptoms, mental status changes, and signs of hypoperfusion and end-organ dysfunction meets the clinical criteria of cardiogenic shock. The Class 1 recommendation is that in patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemi…
