Cardiology Clinical Case / MCQS / Uworld for Usmle step 2 / case 1 with answer and explanation and references and Educational objective
A
56-year-old man comes to the emergency department complaining of 5 days of
dyspnea. He wakes up during the night with difficulty breathing that keeps him
from going back to sleep. He has never had these symptoms before. The patient's
past medical history is significant for long-standing hypertension and
noncompliance with his
antihypertensive
therapy. He was diagnosed with deep-vein thrombosis 8 years ago after surgery
for a tibial fracture; he received 6 months of anticoagulation. He has a
30-pack-year smoking history. Blood pressure is 182/109 mm Hg and pulse is
110/min and regular. Oxygen saturation
is 90% on room air. Lung auscultation shows bibasilar crackles and scattered wheezes. Which of the
following is the most appropriate next step in management of this patient?
|
A.
Albuterol and corticosteroids . B.
Intravenous amiodarone . C.
Intravenous digoxin . D.
Intravenous furosemide . E.
Intravenous metoprolol . F.
Therapeutic anticoagulation . |
Answer :
D
Explanation:
|
Clinical features of acute decompensated
heart failure |
|
|
Clinical presentation |
•Acute
dyspnea, orthopnea, paroxysmal nocturnal dyspnea •
Hypertension common; hypotension suggests severe disease •
Accessory muscle use, tachycardia, tachypnea •
Diffuse crackles with possible wheezes (cardiac asthma) •Possible
S3, jugular venous distention, peripheral edema |
|
Treatment |
Normal
or elevated blood pressure with adequate end-organ perfusion •
Supplemental oxygen •
Intravenous loop diuretic (eg, furosemide) •
Consider intravenous vasodilator (eg, nitroglycerin) Hypotension
or signs of shock •
Supplemental oxygen •
Intravenous loop diuretic (eg, furosemide) as appropriate •
Intravenous vasopressor (eg, norepinephrine) |
This
patient's clinical presentation (dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, bibasilar crackles, hypoxemia) is consistent with acute pulmonary
edema, most likely due to acute decompensated heart failure (ADHF). ADHF is
most commonly due to left ventricular (LV) systolic or diastolic dysfunction
with or without additional cardiac disease (acute myocardial infarction,
arrhythmias, and acute severe mitral or aortic regurgitation).
However,
pulmonary edema can also occur in the setting of normal LV function in
conditions such as severe hypertension, renal artery stenosis, or severe renal
disease with fluid overload. This patient's ADHF is likely due to uncontrolled
hypertension.
Acute
management of ADHF includes supplemental oxygen and intravenous loop diuretics
(eg, furosemide). Intravenous nitroglycerin is a possible adjunctive therapy in
patients without hypotension, especially those with mitral regurgitation or
symptomatic myocardial ischemia. Intravenous nitroglycerin rapidly decreases
preload to relieve dyspnea and tachycardia associated with pulmonary edema.
This patient also requires further evaluation (eg, serial cardiac markers,
echocardiography) to identify any additional factors contributing to heart
failure.
(Choice A) Bronchodilators such as albuterol and systemic corticosteroids are useful in acute obstructive lung disease. However, this patient's signs of pulmonary edema on examination with uncontrolled hypertension are more consistent with heart failure. This exemplifies the adage "Not all that wheezes is asthma.
(Choice
B) Amiodarone is useful for treating atrial fibrillation and ventricular
arrhythmias in patients with ADHF. However, it is not routinely used in the
management of heart failure in the absence of specific arrhythmias. Tachycardia
is a compensatory response
commonly
seen during ADHF and responds well after adequate cardiac output is established
with diuresis.
(Choice
C) Digoxin is also useful in managing atrial fibrillation and systolic
dysfunction.
Ejection fraction should be assessed prior to initiating digoxin therapy.
(Choice E) Cardioselective beta blockers (eg, carvedilol, sustained-release metoprolol succinate) are beneficial for long-term management of patients with stable heart failure due to LV systolic dysfunction. However, they can acutely worsen heart failure symptoms and should be avoided in ADHF. Beta blockers are initiated in stable patients after adequate diuresis.
Educational
objective:
Acute
decompensated heart failure (systolic or diastolic dysfunction) can present
with acute pulmonary edema. Treatment for patients with acute decompensated
heart failure and pulmonary edema who have normal or elevated blood pressure
includes supplemental oxygen, assisted ventilation as needed, aggressive
intravenous diuresis, and possible vasodilator therapy (eg, nitroglycerine,
nitroprusside).
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