What is the best initial step in managing a 68-year-old man with progressive shortness of breath, orthopnea, and a history of hypertension, type 2 diabetes mellitus, and myocardial infarction, presenting with tachycardia, hypoxemia, jugular venous distension, and bilateral crackles?

Management of Acute Heart Failure in a 68-Year-Old Man with Progressive Shortness of Breath

The best initial step in managing this patient with acute heart failure is a chest X-ray (option D). This patient presents with classic signs of acute heart failure including orthopnea, paroxysmal nocturnal dyspnea, jugular venous distension, S3 gallop, bilateral crackles, and peripheral edema, requiring immediate assessment of pulmonary congestion before initiating appropriate therapy 1.

Clinical Assessment and Diagnosis

This patient's presentation is consistent with Killip Class 2-3 heart failure based on:

• Progressive shortness of breath, orthopnea, and PND
• Vital signs showing tachycardia (102/min), tachypnea (24/min), and hypoxemia (90%)
• Physical exam revealing JVD, S3 gallop, bilateral crackles, and peripheral edema
• History of MI, hypertension, and diabetes as risk factors
• Recent dietary non-adherence with increased salt intake

Why Chest X-ray First?

1. Confirms pulmonary congestion: The European Society of Cardiology guidelines specifically state that "pulmonary congestion can be assessed by portable chest X-rays" 1. This helps quantify the extent of pulmonary edema and guides initial therapy.

2. Rules out alternative diagnoses: While the clinical picture strongly suggests heart failure, a chest X-ray can help exclude other causes of dyspnea such as pneumonia, pneumothorax, or pleural effusion.

3. Establishes baseline: The X-ray provides a baseline for monitoring response to treatment.

Management Algorithm After Initial X-ray

1. Immediate interventions:

   • Administer oxygen to maintain SaO₂ >95% 1
   • Position patient upright to reduce work of breathing
   • Initiate IV loop diuretics (furosemide 20-40mg IV) 1
   • Consider IV nitrates if blood pressure allows (SBP >90 mmHg) 1

2. Secondary diagnostic steps:

   • EKG to assess for ischemia or arrhythmias
   • Laboratory tests (cardiac biomarkers, electrolytes, BUN/Cr)
   • Echocardiography to assess LV function and potential mechanical complications

3. Escalation of care if needed:

   • Non-invasive positive pressure ventilation if respiratory distress persists
   • Inotropic support if hypotension develops
   • Consider invasive hemodynamic monitoring in refractory cases

Why Other Options Are Less Appropriate Initially

• EKG (Option A): While important, the patient's presentation clearly indicates heart failure requiring immediate assessment of pulmonary congestion. The EKG should follow the chest X-ray but is not the best first step 1.

• CT chest (Option B): Too time-consuming and unnecessary for initial management of obvious heart failure. The patient needs prompt treatment rather than detailed imaging.

• CT angiography (Option C): While PE can present similarly, this patient's history of MI, dietary non-adherence, and classic heart failure signs make acute heart failure the most likely diagnosis. CT angiography would delay appropriate treatment and expose the patient to contrast that could worsen renal function.

Important Considerations

• Monitor response to initial therapy through clinical parameters (respiratory rate, oxygen saturation, urine output)
• Reassess frequently for signs of improvement or deterioration
• Be alert for potential complications such as worsening hypoxemia, which may require escalation to non-invasive ventilation or intubation
• Avoid excessive diuresis which can lead to electrolyte abnormalities and hypotension, especially in elderly patients 2

Following this approach will optimize outcomes by promptly confirming the diagnosis and allowing for timely initiation of appropriate therapy for this patient with acute heart failure.