A 50-year-old man with known HFrEF (LVEF 28%) is admitted with acute decompensation. He is on carvedilol, sacubitril/valsartan, and furosemide. Blood pressure is 138/88 mmHg, pulse 96 bpm, oxygen saturation 91% on room air, and JVP is elevated at 10 cm H2O. Which initial intravenous therapy is most appropriate for acute decompensated HF with this hemodynamic profile?

• A Intravenous nitroglycerin infusion
• B Intravenous normal saline 500 mL bolus
• C Intravenous dobutamine
• D Intravenous furosemide bolus and titrated infusion ✓

Explanation

This patient has acute decompensated HF with volume overload (elevated JWP, hypoxia) and adequate blood pressure (138/88 mmHg). The mainstay is intravenous loop diuretics to achieve decongestion. Nitroglycerin is reserved for hypertensive acute HF or when BP is significantly elevated. Dobutamine is for hypoperfusion with low BP. Fluid bolus would worsen congestion in a patient who is already volume overloaded. The DOSE trial established that continuous infusion and higher-dose furosemide strategies are acceptable approaches.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.