GIM Question 1 Instructor

A 65-year old man is admitted to your ward with worsening dyspnea over the last two days. He has noticed increased swelling of his legs, and has had episodes of waking up short of breath for the past two nights. He has a history of congestive heart failure, and is taking furosemide 40mg PO daily at home. Physical exam demonstrates normal heart sounds, crackles at the base of both lungs, and pitting edema at both ankles up to his knees.

1. What clinical syndrome is this patient demonstrating?
   This patient is demonstrating Acute Decompensated Heart Failure. This is a syndrome characterized by dyspnea in the setting of an acute increase in left-sided heart filling pressures, which may lead to pulmonary edema as a result. Heart failure is caused by functional or structural cardiovascular dysfunction, leading to inadequate systemic perfusion. It can be classified into two categories, each with different possible etiologies:
   • Heart failure with reduced ejection fraction
     • Systolic dysfunction
     • Main causes include: coronary artery disease, idiopathic dilated cardiomyopathy, hypertension
   • Heart failure with preserved ejection fraction
     • Diastolic dysfunction
     • Main cause: hypertension
2. What initial steps would you take in the management of this condition?
   Goals of initial management for an acute exacerbation of CHF include symptom management, treating pulmonary edema, and prevention of further volume overload:
   • O₂ supplement
   • Loop diuretic (furosemide)
   • Salt restriction <3g/d
   • Fluid restriction to ~1.5L/d
   • Position sitting up
3. What change, if any, would you make to the patient’s home medication?
   Change furosemide 40mg PO to 40mg IV for greater efficacy. As the patient went into acute decompensated heart failure despite diuretic use at home, an increase in the patient’s diuretic dose is required. The efficacy of furosemide IV is 2x that of furosemide PO. Treating this patient with furosemide 40mg IV (equivalent to 80mg PO) would be an appropriate start point for this patient. If this patient was diuretic-naïve, you could start at a lower dose of furosemide 20mg IV.

Resources

1. Felker GM et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011, 364: 797-805.
2. Heart Failure Society of America, Lindenfeld J et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010, 16:e1.
3. Ware LB and Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med. 2005, 353: 2788-96.
4. Yancy CW et al. 2013 ACC/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013, 62: 147-239. Epub 2013 Jun 5.