Worsening Shortness of Breath in Patient With Hypertension, Afib

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On physical examination, the patient has significant jugular venous pressure, S3, S4, and crackles in both lung bases.
On physical examination, the patient has significant jugular venous pressure, S3, S4, and crackles in both lung bases.

Case:

A 72-year-old man with hypertension and paroxysmal atrial fibrillation presents to the emergency department having experienced worsening shortness of breath during the last week.

On physical examination, his heart rate is 65 beats per minute, blood pressure is 145/82 mm Hg, and oxygen saturation on room air is 94%. Further examination reveals that he has significant jugular venous pressure, S3, S4, and crackles in both lung bases. He also has trace bilateral lower extremity edema and an apical holosystolic murmur.

A bedside echocardiogram is performed in the emergency department and reveals a left ventricular ejection fraction of 65%, mild to moderate left ventricular hypertrophy, moderate mitral regurgitation, and pulmonary artery systolic pressure estimated at 52 mm Hg. His electrocardiogram is consistent with left ventricular hypertrophy.

Concerned a pulmonary embolism may be present, the emergency department physician orders a pulmonary computed tomographic angiogram, which was negative for a pulmonary embolism. The patient is currently receiving metoprolol succinate, amiodarone, furosemide, and warfarin.

What is the next best step?

A. Start nifedipine

B. Start ambrisentan and tadalafil

C. Change the oral furosemide to an intravenous administration and increase the dose

D. Refer the patient for a right heart catheterization

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