Question

An 82-year-old woman is brought to the emergency department by her daughter because of shortness of breath. Each night for the past week, the patient has awakened with shortness of breath; she has found that using three pillows instead of one allows her to breathe more easily at night. Two days ago, she had shortness of breath with exertion, and 8 hours ago, she had the sudden onset of mild shortness of breath at rest. She also has a 4-day history of swelling of her ankles and feet. Her only medication is 81-mg of aspirin. On arrival, she is in mild respiratory distress but able to speak in complete sentences. Her temperature is 37°C (98.6°F), pulse is 86/min, respirations are 16/min, and blood pressure is 162/88 mm Hg. Examination shows jugular venous distention. Bilateral basilar crackles are heard over the lower quarter of the lung fields. Cardiac examination shows a regular rhythm. A grade 2/6 holosystolic murmur is heard best at the apex with the patient in the left lateral decubitus position. There is 2+ pitting edema of the ankles. In addition to furosemide, administration of which of the following is the most appropriate next step in pharmacotherapy?

Options:

A) Digoxin

B) Dobutamine

C) Lisinopril

D ) Milrinone

E) Nifedipine

F) Nitroprusside

Correct Answer: C) Lisinopril

Patient Age: 82 years
⬇️
Decreased myocardial function
⬇️
Increased vascular stiffness

Hypertension Present
⬇️
BP: 162/88 mm Hg
⬇️
Heart workload ↑

Fluid Retention Mechanisms Activated
⬇️
Increased renin-angiotensin-aldosterone system (RAAS) activity 🧠
⬇️
Sodium and water retention ↑

Fluid Accumulation in Tissues
⬇️
Swelling of ankles and feet (2+ pitting edema)
⬇️
Increased left atrial pressure
⬇️
Pulmonary congestion (bilateral basilar crackles)
⬇️
Jugular venous distention (JVD)

Symptoms Manifest
⬇️
Orthopnea (requires 3 pillows)
⬇️
Paroxysmal nocturnal dyspnea (PND)
⬇️
Dyspnea on exertion (sudden onset)

Cardiac Output Decreased 🧠
⬇️
Compensatory mechanisms activated:
⬇️
Sympathetic nervous system ↑
⬇️
Further fluid retention ↑

Current Treatment Considerations
⬇️
Furosemide Administered (diuresis)
⬇️
Need for additional therapy identified

Pharmacotherapy Options Explained

A) Digoxin
⬇️
Not first-line in acute heart failure; improves contractility but slower action

B) Dobutamine
⬇️
Used for severe heart failure; not necessary for mild distress

C) Lisinopril (Correct Answer)
⬇️
ACE inhibitor reduces afterload 🧠
⬇️
Improves cardiac output and manages hypertension

D) Milrinone
⬇️
Increases cardiac output but typically reserved for advanced heart failure

E) Nifedipine
⬇️
Calcium channel blocker; can worsen heart failure symptoms

F) Nitroprusside
⬇️
Used for acute hypertensive crisis; may cause hypotension in heart failure

Flashcards

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