Review Question - QID 103653

This patient is suffering an episode of acute decompensated heart failure. The patient's history of ischemic cardiomyopathy and CHF along with a negative troponin level point toward this diagnosis. This patient is volume-overloaded and requires a diuretic to decrease preload to his heart. Furosemide, a loop-diuretic, will decrease preload and is the best choice. (Note that the other drugs listed are used for chronic CHF management and/or in the case of CHF refractory to furosemide treatment.)

Acute decompensated heart failure is also known as acute congestive heart failure (CHF) exacerbation. Congestive heart failure is the inability of the heart to pump blood sufficiently to meet the metabolic demands of the body, or the ability to do so only at abnormally high cardiac filling pressures. In systolic heart failure, the heart cannot expel blood sufficiently, while in diastolic heart failure the heart cannot relax and fill with blood normally. Systolic heart failure is demonstrated by a decreased ejection fraction.

Vine reviews the etiologies and treatment of congestive heart failure: "Causes of congestive heart failure include hypertension, coronary artery disease, alcohol abuse and valvular heart disease...Medical management primarily consists of vasodilators, diuretics and inotropic agents."

The patient described in the question stem is based on the patient seen in the case report by Paul et al. who presented with acute decompensated heart failure and received 20 mg/hr IV furosemide on admission, followed by mitolazone and dobutamine on hospital day 2 in an attempt to increase diuresis.

Image A shows the classic appearance of a chest radiograph of a patient with CHF exacerbation. Note the pulmonary edema and cardiomegaly typical of this disease.

Incorrect answers:
Answer 1: Enalapril is an ACE inhibitor that decreased mortality when used in the treatment of systolic heart failure. It is not the most appropriate first line agent for ADHF in this patient.
Answer 3: Dobutamine is sympathomimetic used in the treatment of heart failure, but furosemide is a more appropriate first line agent in this patient.
Answer 4: Hydralazine is used in the treatment of hypertension and is not the most appropriate first line agent in the treatment of this patient.
Answer 5: Dopamine is an ionotropic and chronotropic drug used in the treatment of heart failure. However, furosemide is a more appropriate first line agent in this patient.