Review Question - QID 213801

This patient is presenting after a myocardial infarction (thus, the deep Q waves and likely decreased ejection fraction) with dyspnea and a chest radiograph with pulmonary edema suggesting a diagnosis of pulmonary edema from poor cardiac function. In the setting of his fluid overloaded state, loop diuretics such as furosemide (and bilevel positive airway pressure) are appropriate management.

Myocardial infarction presents with chest pain, shortness of breath, and diaphoresis in the setting of ST elevation in a vascular territory. Initial management requires administration of aspirin, clopidogrel/tigrecalor, heparin, and cardiac catheterization. After a myocardial infarction, patients may demonstrate pathologic Q waves secondary to the damaged myocardium. Similarly, after a myocardial infarction, impaired cardiac function can lead to heart failure and fluid overload including symptoms of dyspnea, crackles and wheezes, jugular venous distention, and pitting lower extremity edema. Increased hydrostatic pressure within the pulmonary vessels causes pulmonary edema which can cause dyspnea and hypoxia. These patients can be treated with BiPAP (which directly increases pressure in the alveoli forcing fluid out and improving oxygenation) and diuretics to remove the extra fluid.

Figure A is a chest radiograph with notable pulmonary edema throughout both lung fields which is the likely explanation for this patient's dyspnea.

Incorrect Answers:
Answer 1: Albuterol and ipratropium nebulizer would be appropriate management of a COPD flare; however, this patient's wheezing and crackles in the setting of pulmonary edema on chest radiograph suggests a diagnosis of pulmonary edema.

Answer 2: Aspirin and cardiac catheterization would be appropriate management of a new myocardial infarction; however, this patient has no new ST elevation on ECG and his troponins are stable (and are likely persistently elevated from the previous myocardial infarction). His troponins would be uptrending if there was a new infarction.

Answer 3: Digoxin would increase cardiac contractility and could reduce pulmonary edema; however, it would increase the work of the heart which would increase oxygen demand in a post-myocardial infarction heart.

Answer 5: Normal saline would actually worsen this patient's pulmonary edema as he is currently fluid overloaded.

Bullet Summary:
Pulmonary edema can occur after a myocardial infarction secondary to decreased cardiac function and can be treated with loop diuretics.