Worsening Shortness of Breath in Patient With Hypertension, Afib

Answer: C. Change the oral furosemide to an intravenous administration and increase the dose

Discussion:

This gentleman is presenting with group 2 pulmonary hypertension (PH), which is common in patients with severe symptomatic mitral valve disease.1,2 The best next step would be to diuresis him. Starting a calcium channel blocker (choice A) maybe appropriate in patients with group 1 PH only after a right heart catheterization has been performed showing a significant vasodilator response.1

In group 2 PH, calcium channel blockers can be helpful in managing blood pressure to improve afterload conditions and forward flow. However, in this patient presenting with evidence of volume overload (jugular venous distension, crackles, and lower extremity edema), the first step would be diuresis.2 

Starting ambrisentan and tadalafil for group 2 PH would be inappropriate (answer B).1 If the cause of the PH remains unclear, sending the patient for right heart catheterization (answer D) may be an appropriate downstream approach to determining the underlying etiology for the PH (eg, truly PH, or the result of a left heart problem.1

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References

  1. Galiè N, Humbert M, Vachiery JL, et al; for the ESC Scientific Document Group. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119.
  2. Nishimura RA, Otto CM, Bonow RO, et al; for the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.