What is the likely diagnosis and management for an elderly patient with hypertensive heart disease and chronic kidney disease (CKD) presenting with chest pain, nausea, vomiting, hypoxemia, and wheezing?

Acute Decompensated Heart Failure with Cardiogenic Pulmonary Edema

This elderly patient with hypertensive heart disease and CKD presenting with chest pain, nausea/vomiting, severe hypoxemia (O2 sat 82% on 5L), and diffuse wheezing most likely has acute decompensated heart failure (ADHF) with cardiogenic pulmonary edema, potentially precipitated by acute coronary syndrome or hypertensive crisis.

Immediate Diagnostic Priorities

The diagnosis of heart failure is primarily based on signs and symptoms, with immediate assessment of adequacy of systemic perfusion, volume status, and identification of precipitating factors 1. The combination of chest pain, respiratory distress, and hypoxemia in this patient requires urgent evaluation to exclude:

• Acute coronary syndrome - obtain immediate ECG and cardiac troponin testing, as ACS is a common precipitant of acute heart failure hospitalization 1
• Severe hypertension - measure blood pressure immediately, as hypertensive crisis is a recognized precipitant of acute heart failure 1
• Pulmonary embolism - consider in the differential given chest pain and hypoxemia 1

Obtain chest radiograph, electrocardiogram, and prepare for echocardiography as these are key tests in the assessment of acute heart failure 1. Measure BNP or NT-proBNP levels, as these should be obtained in patients being evaluated for dyspnea when the contribution of heart failure is not known 1.

Understanding the Clinical Presentation

The "wheezing on all lobes" represents cardiac asthma - bronchospasm secondary to pulmonary edema from elevated left ventricular filling pressures 1, 2. This is distinct from primary pulmonary disease and occurs when:

• Left ventricular diastolic or systolic dysfunction results in increased preload, leading to pulmonary congestion 2
• Fluid accumulates in the interstitium and alveoli, causing airway compression and bronchial hyperreactivity 1, 2
• The nausea and vomiting likely reflect visceral congestion and reduced organ perfusion 2

In patients with hypertensive heart disease and CKD, left ventricular hypertrophy is present in almost 80% of cases, which predisposes to both diastolic dysfunction and increased risk of acute decompensation 3.

Immediate Management Algorithm

Step 1: Stabilize Oxygenation and Hemodynamics

Administer oxygen immediately to achieve arterial oxygen saturation ≥95% 1. Given the severe hypoxemia (82% on 5L):

• Consider non-invasive ventilation (NIV) with positive end-expiratory pressure (PEEP) as early as possible - NIV improves clinical parameters including respiratory distress and reduces both the need for intubation and short-term mortality in acute cardiogenic pulmonary edema 1
• Start with PEEP of 5-7.5 cmH2O, titrate to clinical response up to 10 cmH2O with FiO2 0.40 1
• NIV with PEEP improves left ventricular function by reducing LV afterload 1

Step 2: Initiate Diuretic Therapy Without Delay

Patients admitted with heart failure and evidence of significant fluid overload should be treated with intravenous loop diuretics, with therapy beginning in the emergency department without delay 1. Early intervention may be associated with better outcomes 1.

However, given this patient's CKD, exercise caution with dosing:

• Administer initial bolus of furosemide 40 mg IV (or higher dose based on renal function and history of chronic oral diuretic use) 1
• In patients with evidence of volume overload and renal dysfunction, the dose may need to be increased, but total furosemide dose should remain <100 mg in the first 6 hours and <240 mg during the first 24 hours 1
• Place bladder catheter to monitor urinary output and rapidly assess treatment response 1
• Patients with hypotension (SBP <90 mmHg), severe hyponatremia, or acidosis are unlikely to respond to diuretic treatment 1

Step 3: Address Chest Pain and Anxiety

Morphine should be considered in the early stage of treatment, especially if the patient presents with restlessness, dyspnea, anxiety, or chest pain 1.

• Administer IV boluses of morphine 2.5-5 mg as soon as IV line is inserted, repeat as required 1
• Morphine relieves dyspnea and improves cooperation for NIV application 1
• Monitor respiration closely and have antiemetic therapy available, as nausea is common 1
• Use caution if hypotension, bradycardia, or CO2 retention is present 1

Step 4: Monitor Critical Parameters

Measure fluid intake and output, vital signs, and clinical signs of systemic perfusion and congestion serially 1.

Obtain daily serum electrolytes, urea nitrogen, and creatinine concentrations during use of IV diuretics 1. This is particularly critical in CKD patients where:

• Renal function decline aggravates hypertension and fluid retention 4, 5
• Electrolyte imbalances (particularly hyperkalemia) can cause life-threatening cardiac dysrhythmias 6
• Volume depletion from aggressive diuresis can worsen renal function 1

Escalation Strategy if Initial Treatment Inadequate

When diuresis is inadequate to relieve congestion, intensify the diuretic regimen using:

1. Higher doses of loop diuretics 1
2. Addition of a second diuretic such as metolazone, spironolactone, or intravenous chlorothiazide 1
3. Continuous infusion of a loop diuretic 1

Thiazides in combination with loop diuretics may be useful in cases of diuretic resistance 1. However, in elderly patients with CKD, thiazides are often ineffective due to reduced glomerular filtration 1.

Critical Pitfalls to Avoid

Do not attribute wheezing solely to COPD or asthma without considering cardiac causes - the combination of chest pain, nausea, and severe hypoxemia in a patient with hypertensive heart disease strongly suggests cardiogenic pulmonary edema 1, 2.

Do not delay NIV while waiting for chest radiograph results - clinical presentation of respiratory distress with hypoxemia warrants immediate respiratory support 1.

Do not use excessive diuretic doses in CKD patients - high doses may lead to hypovolemia, hyponatremia, and worsening renal function 1. Alternative treatment options such as IV vasodilators may reduce the need for high-dose diuretic therapy 1.

Do not overlook acute coronary syndrome as the precipitant - chest pain in this context requires immediate ECG and troponin testing, as ACS commonly precipitates acute heart failure and requires specific treatment 1.

Monitor for intubation criteria - intubation and mechanical ventilation should be restricted to patients in whom oxygen delivery is not adequate by oxygen mask or NIV, and in patients with increasing respiratory failure or exhaustion as assessed by hypercapnia 1.