Review Question - QID 215188

This patient with multiple risk factors for heart disease (diabetes, hypertension, obesity, and a lack of a medical doctor as a provider) is presenting with dyspnea, hypoxia, crackles/wheezes on lung exam, lower extremity edema, and a chest radiograph demonstrating pulmonary edema suggestive of a heart failure exacerbation. This patient's heart failure exacerbation is likely secondary to his elevated blood pressure and should next be treated with a nitroglycerin drip.

Heart failure occurs secondary to conditions such as ischemia, aging, hypertension, or previous infarctions and occurs when the systolic function of the heart is impaired. The heart is often dilated with a reduced ejection fraction. Physical exam will reveal an S3, pitting lower extremity edema, and jugular venous distension. Illness, a high salt diet, ischemia, or a worsening of the patient's underlying cardiac function can lead to a heart failure exacerbation. Heart failure exacerbations present with dyspnea, wheezing, crackles, and hypoxia. Appropriate management includes loop diuretics and bilevel positive airway pressure. Hypertension can often worsen symptoms. Nitroglycerin is a potent venodilator that reduces preload and afterload; this in turn leads to improved symptoms via decreased blood in the pulmonary vasculature and decreased pulmonary edema.

Uil et al. review the use of intravenous nitroglycerin in the management of acute decompensated heart failure. The authors find that nitroglycerin leads to improvements in clinical outcomes such as lower rates of mechanical ventilation and improved survival. The authors recommend the use of nitrates in hypertensive patients with heart failure exacerbations.

Figure/Illustration A is a chest radiograph demonstrating pulmonary edema with the most congested areas with the worst edema noted by red circles which are likely secondary to this patient's heart failure and hypertension.

Incorrect Answers:
Answer 1: Digoxin inhibits the Na/K ATPase leading to increased intracellular calcium in the cardiac myocyte causing increased cardiac contractility. It may reduce hospitalizations for heart failure exacerbations but does not reduce mortality and is not indicated in the management of acute decompensated heart failure secondary to hypertension.

Answer 2: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor which is a preferred blood pressure medication in heart failure as it reduces mortality and can reduce cardiac remodeling. It would not be indicated as the initial management of an acute heart failure exacerbation; however, it can be started for this patient as an outpatient medication or once the patient is stabilized.

Answer 3: Metoprolol is a beta-blocker that all patients with heart failure should be on as it reduces mortality via reducing cardiac oxygen demand. However, an acute heart failure exacerbation may be worsened by beta-blocker administration as it would further decrease cardiac contractility.

Answer 5: Nitroprusside could be used to lower this patient's blood pressure; however, it is not the preferred agent for an acute heart failure exacerbation with pulmonary edema. A preload and afterload reducer such as nitroglycerin would be a better option.

Bullet Summary:
Heart failure exacerbations with concomitant hypertension can be treated with nitroglycerin which reduces preload and afterload thus mitigating symptoms.