A 53-year-old woman with a history of CHF presents to the emergency room (ER). She is cool and clammy. She reports being short of breath. Her blood pressure (BP) is 71/40 mmHg, her heart rate (HR) is 110 bpm, and her respiratory rate is 30. She has elevated neck veins and a prominent S3 . Her echocardiogram (ECG) shows sinus tachycardia. She is admitted to the CCU (coronary care unit) with heart failure. A pulmonary artery (PA) catheterization is performed, and her hemodynamics are as follows: right atrial (RA) pressure, 12 mmHg; PA pressure, 62/30 mmHg; cardiac output, 1.9 L/min/m2 ; pulmonary capillary wedge pressure (PCWP), 36 mmHg; and systemic vascular resistance (SVR), 2,000 dyne/s/cm5 .
This patient continues to deteriorate after your initial treatment. Her BP is 64/32 mmHg, and her HR is 132 bpm. She is now intubated on maximal pressor support and has an IABP in place.
Which of the following should be your next therapeutic option?
Consider LV assist device. This is a relatively young patient with no contraindication to cardiac transplant. However, in the current state, she is not eligible for transplantation. LV assist device as a bridge to transplant has been performed with success.
A 35-year-old man with a history of HTN presents to the ER in respiratory distress. He is intubated in the ER for respiratory distress. His BP is 73/48 mmHg, his HR is 130 bpm, and his respiratory rate is 20. He is taken to the medical ICU (intensive care unit), and a PA catheterization is performed. His hemodynamics are as follows: RA pressure, 22 mmHg; PA pressure, 20/10 mmHg; cardiac output, 3.5 L/min/m2 ; PCWP, 12 mmHg; and SVR, 1,690 dyne/s/cm5 .
What is your diagnosis?
Acute right ventricular (RV) failure. His hemodynamic pressures are characteristic of acute RV failure. He needs aggressive fluid resuscitation.
You receive a call from a cardiologist in a small community hospital regarding a patient in heart failure. She states that the patient was admitted last night with heart failure and was started on intravenous (IV) nitroglycerin; IV furosemide infusion; captopril, 12.5 mg t.i.d.; and digoxin. There has been no improvement; therefore, the cardiologist placed a SwanGanz catheter this morning. The patient’s hemodynamics are as follows: BP, 120/89 mmHg; HR, 89 bpm; cardiac output, 2.0 L/min/m2 ; PCWP, 29 mmHg; and SVR, 1,766 dyne/s/cm5 . The cardiologist also added dobutamine.
Which of the following additional therapies should you recommend to the cardiologist for this patient?
Suggest nitroprusside. This patient is in heart failure and needs to have her BP and SVR lowered. BP is adequate and does not need vasopressor or IABP support. Although nesiritide has been approved for use in acute heart failure, it only mildly lowers the BP.
A 57-year-old woman, who experienced inferior wall MI in 1992, has an EF of 30% and was diagnosed with nonsustained ventricular tachycardia (VT) (four beats of VT) at another hospital on a routine ECG that she needed before cataract surgery. She has been in excellent health and has never been hospitalized for CHF. She has never had palpitation or syncopal episodes. Her doctors advised her that she would need an implantable defibrillator. She does not agree and wants a second opinion. She wants to know whether there is any evidence to support the implantable defibrillators.
What is your advice?
Place an implantable defibrillator. She fits the criteria of the initial Multicenter Automatic Defibrillator Trial (MADIT). Therefore, based on randomized clinical trial data, she would benefit from an implantable defibrillator. Also, secondary prevention trials such as the Antiarrhythmics Versus Implantable Defibrillators Trial, the Canadian Implantable Defibrillator Study, and the Cardiac Arrest Study Hamburg trial also support an implantable defibrillator in this patient.
A 49-year-old man is admitted with new-onset heart failure. He is diagnosed with dilated cardiomyopathy with an EF of 20%. On hospital day 1, he is diuresed and started on a regimen of furosemide, digoxin, acetylsalicylic aspirin, captopril, and simvastatin. A medical student wants to know why you did not start him on a β-blocker.
What is your explanation?
β-Blockers should be started in stable CHF patients. They should not be started when the patient is congested. Although nonselective agents with vasodilating effects may be preferred, this is not clear at this time.
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