How to manage a patient with paroxysmal atrial fibrillation, essential hypertension, and chronic kidney disease stage 2, presenting with acute CHF exacerbation (bilateral lower extremity edema, orthopnea) on furosemide, apixaban, sotalol, amlodipine, losartan, and other medications?

Management of Acute CHF Exacerbation in a Patient with Paroxysmal Atrial Fibrillation, Hypertension, and CKD Stage 2

Immediately increase IV furosemide to a dose at least equal to or exceeding the current oral daily dose, as this patient presents with acute decompensated heart failure evidenced by recurrent bilateral lower extremity edema, new orthopnea, and pulmonary crackles. 1, 2

Immediate Diuretic Management

• Administer IV furosemide at a dose equal to or greater than the current oral daily dose within 60 minutes of assessment, as early aggressive diuresis improves outcomes in acute CHF exacerbation 1, 2
• The initial IV dose should be at least 20-40 mg for diuretic-naive patients, but for patients already on chronic oral diuretics (as in this case), the IV dose must equal or exceed the chronic oral daily dose 1
• If congestion persists after initial diuretic therapy, intensify the regimen by either doubling the loop diuretic dose or adding a second diuretic agent (thiazide or spironolactone) 1, 2
• Diuretics can be administered as intermittent boluses or continuous infusion; adjust dose and duration according to symptoms, urine output, and clinical status 1

Monitoring During Diuresis

• Monitor daily weights, strict fluid intake/output, symptoms, renal function (BUN, creatinine), and electrolytes (particularly potassium) during IV diuretic therapy 1, 3, 2
• The current labs show eGFR 63 mL/min (CKD stage 2) and potassium 3.8 mEq/L, which are acceptable for diuretic intensification, but close monitoring is essential as diuresis may transiently worsen renal function 1, 3
• The elevated CO2 of 38 mmHg may reflect chronic compensatory alkalosis from loop diuretic use 1

Continue Guideline-Directed Medical Therapy

• Continue apixaban, sotalol, amlodipine, and losartan unless hemodynamic instability or contraindications develop 1, 2
• In patients with acute decompensated HF on chronic GDMT, continuation of ACE inhibitors/ARBs and beta-blockers during hospitalization is well-tolerated and results in better outcomes 1, 2
• Do not discontinue beta-blocker (sotalol) unless the patient develops marked volume overload, marginal/low cardiac output, or was recently initiated on beta-blocker therapy 1

Anticoagulation Considerations with CKD

• Continue apixaban for paroxysmal atrial fibrillation, but verify the dose is appropriate given CKD stage 2 (eGFR 63) 4
• With eGFR >50 mL/min, standard apixaban dosing (5 mg twice daily) is appropriate unless other dose-reduction criteria are met (age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL) 4
• Current creatinine is 0.88 mg/dL, which does not meet dose-reduction criteria 4

Blood Pressure Management

• BP of 142/59 mmHg is mildly elevated and likely volume-related; continue current antihypertensive regimen (amlodipine, losartan) and monitor BP response during diuresis 1
• The systolic hypertension supports the use of vasodilators if needed for symptom relief, as IV vasodilators should be considered for symptomatic relief in acute HF with SBP >90 mmHg 1

Aldosterone Antagonist Consideration

• Consider adding spironolactone 12.5-25 mg daily if congestion persists despite optimized loop diuretic therapy, as aldosterone antagonists can decrease hospitalizations in appropriately selected patients 1
• Current potassium is 3.8 mEq/L and eGFR is 63 mL/min, which are within acceptable ranges for initiation (K+ ≤5.0 mEq/L, eGFR ≥30 mL/min) 1
• Monitor potassium closely after initiation; hold if K+ rises above 5.0 mEq/L 1

Respiratory Support

• Administer supplemental oxygen if SpO2 falls below 90%, but avoid hyperoxia 1, 2
• Current SpO2 is 95% on room air, which is acceptable 1
• If respiratory distress develops, initiate non-invasive positive pressure ventilation (CPAP or BiPAP) immediately, as this reduces intubation rates and may decrease mortality 1, 2

Agents to Avoid

• Do not use inotropic agents (dobutamine, milrinone) unless the patient becomes hypotensive (SBP <90 mmHg) or develops signs of hypoperfusion, as they raise safety concerns and are associated with adverse outcomes 1, 2
• Avoid morphine for dyspnea relief, as it is associated with higher rates of mechanical ventilation, ICU admission, and death 2

Diagnostic Testing

• Await STAT chest X-ray results to assess for pulmonary edema and guide further management 3, 2
• The presence of left upper lobe crackles on exam is concerning for pulmonary congestion 1, 3

Non-Pharmacologic Interventions

• Reinforce daily use of compression stockings and leg elevation above heart level to reduce lower extremity edema 3
• Provide low-sodium diet counseling (<2 grams sodium daily) to reduce congestive symptoms 1
• Continue melatonin for sleep disturbance, as addressing the underlying volume overload is the primary treatment for orthopnea 1

Follow-Up and Discharge Planning

• Do not discharge until the patient is hemodynamically stable for at least 24 hours, euvolemic, established on evidence-based oral medications, and has stable renal function for at least 24 hours 2
• Verify electrolytes and renal function after any diuretic adjustment before discharge 3, 2