In a 60-year-old man with acute decompensated heart failure presenting with severe hypertension, tachycardia, tachypnea, elevated jugular venous pressure, bilateral crackles and use of accessory muscles, which intravenous medication should be given first?

Initial Intravenous Medication for Acute Decompensated Heart Failure with Hypertensive Crisis

In this 60-year-old man presenting with acute decompensated heart failure and severe hypertension (BP 160/100 mmHg), intravenous vasodilators (nitrates) should be administered first, followed immediately by intravenous loop diuretics (furosemide). 1

Clinical Presentation Analysis

This patient presents with classic hypertensive acute heart failure, characterized by:

• Severe hypertension (BP 160/100 mmHg) 2
• Markedly elevated jugular venous pressure (15 cm H₂O) indicating volume overload 2
• Bilateral crackles from base to apex indicating pulmonary edema 2
• Use of accessory muscles and tachypnea (RR 32/min) indicating respiratory distress 2
• Tachycardia (HR 120 bpm) as a compensatory response 2

This clinical picture corresponds to Type II acute heart failure (hypertensive AHF) in the European classification, where signs and symptoms are accompanied by high blood pressure with relatively preserved left ventricular function and acute pulmonary edema. 2

Immediate Treatment Algorithm

First-Line: Intravenous Vasodilators (Nitrates)

IV vasodilators should be initiated immediately because this patient has adequate blood pressure (SBP >110 mmHg) and presents with the hypertensive phenotype of acute heart failure. 2, 1

• Target blood pressure reduction: Decrease systolic BP by 30 mmHg within the first few minutes, then continue gradual reduction over several hours. 1
• Mechanism: Nitroglycerin causes venous dilatation promoting peripheral blood pooling, reducing venous return and left ventricular end-diastolic pressure (preload reduction), while also causing arteriolar relaxation to reduce systemic vascular resistance and afterload. 3
• Rationale: The pathophysiology of hypertensive acute heart failure involves progressive excessive vasoconstriction superimposed on reduced left ventricular functional reserve, creating a vicious cycle of afterload mismatch. 4 Breaking this cycle with rapid vasodilation is the priority. 4

Second-Line (Simultaneous): Intravenous Loop Diuretics

IV furosemide should be administered concurrently to address volume overload evidenced by the elevated JVP and bilateral crackles. 5, 1

• Dosing: If the patient is diuretic-naïve, start with 40 mg IV furosemide; if on chronic oral diuretics, the IV dose must equal or exceed the total daily oral dose. 2, 5
• Monitoring: Track urine output, daily weights, renal function, and electrolytes. 2, 5

Why Not the Other Options?

Digoxin (Option A) - Incorrect

• Digoxin has no role in the acute management of decompensated heart failure with pulmonary edema and hypertension. 2
• It is only considered for rapid ventricular rate control in patients with heart failure and atrial fibrillation, which is not mentioned in this case. 2

Adenosine (Option B) - Incorrect

• Adenosine is indicated for orthodromic AVRT (supraventricular tachycardia), not for acute heart failure. 2
• The tachycardia in this patient (HR 120 bpm) is a compensatory response to heart failure and hypertension, not a primary arrhythmia requiring adenosine. 2

Furosemide Alone (Option C) - Partially Correct but Incomplete

• While furosemide is essential and should be given, vasodilators must be the priority in hypertensive acute heart failure. 1
• Studies show that early administration of IV vasodilators is associated with lower mortality, and delays in vasodilator administration are associated with higher mortality. 2
• The European guidelines specifically state that IV vasodilators are indicated in AHF with normal to high BP and should be combined with diuretics. 2, 1

Critical Management Points

Avoid these common pitfalls:

• Do not use inotropes (dobutamine, milrinone) in this normotensive patient without evidence of hypoperfusion, as they increase mortality. 5, 6
• Do not use morphine routinely, as it was associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry. 2
• Do not stop beta-blockers or ACE inhibitors/ARBs unless the patient develops hemodynamic instability (SBP <85 mmHg). 2, 5

This patient requires ICU/CCU admission based on respiratory rate >25/min, use of accessory muscles, and SpO₂ likely <90%. 2, 6

Answer: d. Nitrates (with immediate addition of furosemide)

The correct initial IV medication is nitrates (vasodilators), which should be given simultaneously with furosemide to address both the excessive vasoconstriction and volume overload that characterize hypertensive acute heart failure. 1, 4