Case #1 Answers:

Answer 1
Most patients, as this one, have multiple reasons for exacerbations of CHF. Etiologies in this
patient might include:
a. non-compliance (or lack of education) with dietary restrictions or medications
b. inappropriate medical regimen
c. worsening of LV function secondary to alular dysfunction or ischemia
d. anemia of renal failure
e. inappropriate medications such as NSAIDS that cause salt retention


 

Answer 2
A search for the above etiologies would be justified if suspected.  For this patient, CBC, BUN, and creatinine are appropriate. A non-invasive study to evaluate for ischemia is also appropriate at this time.  A resting cardiogram to check for bundle branch block should be ordered.  Assessment of LV function is probably not warranted unless there is the suspicion of worsening valvular disease and a plan for surgical repair.
 

Answer 3
This is controversial and patient specific.  However, for mild exacerbations of chronic heart failure, as in our patient, hospitalization should be avoided and patients should be managed closely on an outpatient basis.
 

Answer 4
The patient will feel better with an increase in the dose of the  loop diuretic.  However, fluid restriction and low sodium diet may be all that is needed along with proper education.    This patient might also benefit from the addition of spironolactone and low dose digoxin.  Once the patient is less volume overloaded, beta-blocker therapy with either carvedilol or metoprolol XL could be started at low doses and titrated as tolerated.

 

Answer 5
Beta-blockers, ACE inhibitors, and spironolactone have all been shown in large randomized clinical trails to improve mortality in patients with CHF associated with a low EF.  Carvedilol has been shown to improve mortality by over 60%.  The mortality benefit from ACE inhibitors or spironolactone is about half that of Carvedilol.
 

Answer 6
Patients with current decompensated failure, or Class IV CHF should not be started on beta-blockade.  Likewise, patients with bradyarrhythmias or heart block, hypersensitivity to beta-blockers, and reactive airway disease should not receive the drug.