What is the best course of action for an elderly female with a history of congestive heart failure (CHF) presenting to the emergency room (ER) with shortness of breath and chest pain, after being diagnosed with coronavirus and pneumonia two days ago, and having multiple ER visits?

Hospital Admission is Strongly Recommended for This High-Risk Patient

This elderly female with CHF, recent COVID-19 pneumonia diagnosis, and recurrent ER presentations with chest pain and dyspnea requires immediate hospital admission for comprehensive monitoring, diagnostic workup to differentiate cardiac from pulmonary etiologies, and escalation of therapy as needed. 1, 2

Rationale for Admission

Critical Risk Factors Present

• Pre-existing CHF significantly increases mortality risk in COVID-19 patients, with a pooled relative risk of 2.35 for in-hospital mortality 3
• Multiple ER visits within 48 hours indicate inadequate outpatient management and progressive clinical deterioration 4
• Elderly age combined with cardiac comorbidity places her at highest risk for severe COVID-19 complications and death 5
• Chest pain in COVID-19 with CHF requires urgent differentiation between acute coronary syndrome, myocarditis, pulmonary embolism, and CHF exacerbation 5

Immediate Diagnostic Priorities Upon Admission

Differentiate cardiac from COVID-19 pulmonary causes of her presentation, as this fundamentally changes management 5:

• Obtain troponin levels immediately: Mild elevations (<2-3× ULN) in elderly patients with pre-existing cardiac disease are common with COVID-19 and do not require ACS workup unless accompanied by angina-type chest pain or ECG changes 5
• If troponin >5× ULN: Consider myocarditis, Takotsubo syndrome, type 1 MI, or severe respiratory failure; obtain echocardiography to determine underlying cause 5
• Obtain BNP/NT-proBNP: Elevated levels reflect both pre-existing CHF and acute COVID-19 stress; significantly elevated NT-proBNP correlates with worse outcomes 5, 3
• ECG on arrival: Essential to identify ST-segment changes suggesting type 1 MI versus non-coronary causes 5

Essential Monitoring Protocol

Continuous vital signs monitoring is mandatory 1:

• Heart rate, pulse oximetry (SpO2), respiratory rate, and blood pressure must be monitored continuously 1
• Target SpO2 >90-96%, preferably closer to 96% given risk of "silent hypoxemia" 1

Laboratory monitoring at admission and serially 1:

• Baseline coagulation studies (D-dimer, PT/PTT, platelet count, fibrinogen) - D-dimer >6× ULN predicts thrombotic events and poor prognosis 1
• Comprehensive metabolic panel including liver enzymes (ALT, AST), bilirubin, creatinine, urea nitrogen 1
• CRP and procalcitonin to assess disease severity and identify bacterial superinfection 1
• Monitor coagulation parameters at least twice daily 1

Respiratory Support Escalation Plan

If hypoxemia develops or worsens 2:

• Start with high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) immediately if standard oxygen fails 2
• Critical decision point: If no improvement within 1-2 hours, proceed immediately to intubation and invasive mechanical ventilation 2
• Intubation criteria: PaO2/FiO2 ≤150 mmHg despite HFNO/NIV 2

Pharmacological Management

Corticosteroids if severe disease develops 2:

• Methylprednisolone 40-80 mg daily (not exceeding 2 mg/kg) for rapid disease progression 2
• Strong evidence for reduced mortality in severe COVID-19 2

Thromboprophylaxis intensification 4:

• Given obesity risk, CHF, elevated D-dimers, and hospitalization, intensified thromboprophylaxis is indicated 4

Remdesivir consideration 6:

• May be considered if requiring oxygen therapy but NOT yet on invasive mechanical ventilation 2
• Must be initiated within 7 days of symptom onset for non-hospitalized patients, though she is now presenting for admission 6

Critical Pitfalls to Avoid

• Do not assume chest pain is purely cardiac without excluding pulmonary embolism, given high thrombotic risk in COVID-19 5, 1
• Do not delay intubation if respiratory status deteriorates on HFNO/NIV beyond 1-2 hours 2
• Do not perform coronary angiography for mild troponin elevations without clear ACS features 5
• Do not discharge until clinical stability is achieved and home monitoring is adequate, given her pattern of rapid deterioration 4