What treatment will be ordered for a patient with chronic hypertension, presenting with tachycardia, hypertension, bibasilar crackles, 2+ pitting edema, and jugular venous distension?

From the Guidelines

The provider will likely order furosemide as the first-line treatment for this patient's acute fluid overload and heart failure symptoms. The patient's presentation with bibasilar crackles, 2+ pitting edema of the ankles, and jugular vein distention indicates significant fluid overload, which is a common complication of heart failure 1. Furosemide, a loop diuretic, is the most appropriate immediate intervention to reduce fluid volume, decrease pulmonary congestion, and alleviate peripheral edema, as recommended by the American College of Cardiology Foundation/American Heart Association guidelines for the diagnosis and management of heart failure in adults 1. Key points to consider in this clinical scenario include:

• The patient's history of chronic hypertension and current elevated blood pressure (150/90 mm Hg), which suggests that the heart is working harder to pump blood, contributing to the fluid overload.
• The importance of addressing the acute fluid overload promptly to prevent further complications, such as respiratory distress or cardiac arrhythmias.
• The potential role of other medications, such as ACE inhibitors, beta-blockers, and aldosterone receptor antagonists, in managing chronic heart failure, but furosemide is the most appropriate initial treatment for acute fluid overload 1. The use of furosemide in this scenario is supported by the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults, which recommends the use of loop diuretics in patients with evidence of significant fluid overload 1. Additionally, the 2015 scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension recommends the use of loop diuretics in patients with severe heart failure or those with severe renal impairment 1.

From the FDA Drug Label

Furosemide may add to or potentiate the therapeutic effect of other antihypertensive drugs. Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs. Furosemide may decrease arterial responsiveness to norepinephrine However, norepinephrine may still be used effectively.

The patient's symptoms, including bibasilar crackles, 2+ pitting edema of the ankles, and distention of the jugular veins, suggest fluid overload and congestive heart failure. Given this clinical presentation, the provider will likely order Furosemide, a loop diuretic, to help alleviate the fluid overload and reduce the patient's blood pressure. Furosemide can help reduce fluid volume and decrease blood pressure, making it a suitable choice for this patient's condition 2.

From the Research

Assessment and Treatment

The patient's assessment data indicates symptoms of heart failure, including a heart rate of 96 beats/minute, blood pressure of 150/90 mm Hg, bibasilar crackles, 2+ pitting edema of the ankles, and distention of the jugular veins. Based on this data, the provider is likely to order a treatment that addresses the patient's fluid overload and heart failure symptoms.

Treatment Options

The following treatment options are considered:

• Angiotensin-converting enzyme (ACE) inhibitor: ACE inhibitors, such as lisinopril, have been shown to be effective in reducing morbidity and mortality in patients with heart failure 3.
• Digoxin: While digoxin can be used to treat heart failure, it is not typically the first-line treatment for fluid overload and heart failure symptoms.
• Furosemide: Furosemide is a loop diuretic that is commonly used to treat fluid overload in patients with heart failure. Studies have shown that furosemide can be effective in reducing fluid overload and improving symptoms in patients with heart failure 4, 5, 6.
• Spironolactone: Spironolactone is a potassium-sparing diuretic that can be used to treat heart failure, but it is not typically the first-line treatment for acute fluid overload.

Likely Treatment Order

Based on the patient's symptoms and the available evidence, the provider is likely to order furosemide to treat the patient's fluid overload and heart failure symptoms. Furosemide has been shown to be effective in reducing fluid overload and improving symptoms in patients with heart failure, and it is a commonly used treatment for this condition 4, 5, 6. The provider may also consider ordering an ACE inhibitor, such as lisinopril, to reduce morbidity and mortality in the patient with heart failure 3.

Key Points

• Furosemide is a commonly used treatment for fluid overload in patients with heart failure.
• ACE inhibitors, such as lisinopril, can reduce morbidity and mortality in patients with heart failure.
• The choice of diuretic and other treatments should be guided by the patient's clinical situation and the presence of other co-morbidities.