MEDizzy - You are evaluating a 64-year-old woman with a history of

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Disorders of the cardiovascular system 2

You are evaluating a 64-year-old woman with a history of nonischemic cardiomyopathy. She presents to the emergency department for shortness of breath. You note that she has gained 11 kg since her last cardiology appointment 2 months ago. Physical examination confirms findings associated with acute decompensated heart failure, including pulmonary rales, elevated jugular venous pulse, abdominal ascites, lower extremity edema, and a square wave blood pressure Valsalva response. Her extremities are warm, and her blood pressure is 110/78 mmHg with a heart rate of 75 bpm. Her laboratory studies return with a sodium of 128 mEq/L and creatinine of 2.5 mg/dL (which is increased from her prior level of 1.2 mg/dL). Chest x-ray shows a difuse alveolar filling pattern consistent with pulmonary edema. What is the next most appropriate step?

ExplanationThis patient clearly has adequate cardiac output to maintain peripheral perfusion as evidenced by her physical examination (warm extremities) and adequate blood pressure. However, her elevated creatinine is vexing and indicates that she suffers from cardiorenal syndrome. In some cases, it truly is a depressed cardiac output causing a low glomerular filtration rate (GFR); however, these cases are typically accompanied by other signs of peripheral malperfusion. In most cases when cardiac output is not severely depressed, it is thought that a complex interplay of elevated venous pressures (reducing trans glomerular perfusion pressures) and abdominal pressures leads to decreased GFR. In these cases, reducing venous pressures with diuretics is the most reasonable first option. In patients who respond poorly (rising creatinine or adverse hemodynamic effects), hemodynamic monitoring (option A) or ultrafiltration can be considered. Digoxin should be used with caution in renal insufficiency and has no real benefit acutely here. In cases where cardiac output is thought to be severely depressed and peripheral perfusion is compromised, inotropic therapy may be indicated.