RT Book, Section A1 Goldberg, Randal A1 Rao, Shaline A1 Reyentovich, Alexander A2 Baliga, R. R. A2 Abraham, William T. SR Print(0) ID 1161018558 T1 Inotropic Therapy in Heart Failure T2 Color Atlas and Synopsis of Heart Failure YR 2018 FD 2018 PB McGraw-Hill Education PP New York, NY SN 9780071749381 LK accesscardiology.mhmedical.com/content.aspx?aid=1161018558 RD 2024/03/28 AB A 63-year-old female with a history of diabetes, prior myocardial infarction, and an ischemic cardiomyopathy with a left ventricular ejection fraction of 35% presents to the emergency department with shortness of breath with minimal exertion, as well as three pillow orthopnea, and paroxysmal nocturnal dyspnea. Six months prior to presentation, she was able to walk 3-blocks which has progressively worsened. One month prior she was started on Digoxin 0.125 mg in addition to her regimen of Metoprolol Succinate 25 mg, Lisinopril 2.5 mg, Spironolactone 25 mg, Aspirin 81 mg, and Plavix 75 mg (all daily), in addition to Metformin 1000 mg twice-a-day. In the emergency department, her initial vital signs show her to be afebrile, with a heart rate of 102 beats-per-minute, and a blood pressure of 90/66 mm Hg. Examination notes an elevated jugular venous pressure with a positive hepatojugular reflex. She has bibasilar crackles, an S3 on cardiac auscultation, and 1+ pitting edema with cool lower extremities. Chest x-ray demonstrates pulmonary edema, and an ECG shows sinus tachycardia with q-waves in leads V1-V3 (known from previous), and unchanged intervals and ST segments. Initial labs are notable for a sodium of 130 mmol/L, a serum creatinine of 1.6 mg/dL, a lactate of 3.1 mmol/L, and a troponin I of 0.93 ng/mL that remains unchanged 4-hours later. The managing team was confronted with a series of questions regarding the differential diagnosis, prognosis, and next management steps.