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The following question refers to Section 9.5 of the\xa02022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.\xa0\n\nThe question is asked by Keck School of Medicine USC medical student & CardioNerds Intern\xa0Hirsh Elhence, answered first by Duke University cardiology fellow and CardioNerds FIT Ambassador\xa0Dr. Aman Kansal, and then by expert faculty\xa0Dr. Javed Butler.\n\nDr. Butler is an advanced heart failure and transplant cardiologist, President of the Baylor Scott and White Research Institute, Senior Vice President for the Baylor Scott and White Health, and Distinguished Professor of Medicine at the University of Mississippi.\n\nThe\xa0Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure\xa0series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders\xa0Dr. Amit Goyal\xa0and\xa0Dr. Dan Ambinder, with mentorship from\xa0Dr. Anu Lala,\xa0Dr. Robert Mentz, and\xa0Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.\n\nEnjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.\n\n\n\nQuestion #14\n\n\n\nMrs. Hart is a 70-year-old woman hospitalized for a 2-week course of progressive exertional dyspnea, increasing peripheral edema, and mental status changes. She has a history of coronary artery disease, hypertension, and heart failure for which she takes aspirin, furosemide, carvedilol, lisinopril, and spironolactone. On physical exam, the patient is afebrile, BP is 80/60 mmHg, heart rate is 120 bpm, and respiratory rate is 28 breaths/min with O2 saturation of 92% breathing room air. She is sitting upright and is confused. Jugular venous pulsations are elevated. Cardiac exam reveals an S3 gallop. There is ascites and significant flank edema on abdominal exam. Her lower extremities have 2+ pitting edema to her knees and are cool to touch. Her labs are significant for an elevated serum Creatinine of 3.0 from a baseline of 1.0 mg/dL, lactate of 3.0 mmol/L, and liver enzyme elevation in the 300s U/L.\n\nWhich of the following is the most appropriate initial treatment?\n\n\nA\nIncrease carvedilol\n\n\nB\nStart dobutamine\n\n\nC\nIncrease lisinopril\n\n\nD\nStart nitroprusside\n\n\n\n\n\nAnswer #14\n\n\n\nExplanation\nThe Correct answer is B \u2013 start dobutamine.\n\nThis patient with progressive congestive symptoms, mental status changes, and signs of hypoperfusion and end-organ dysfunction meets the clinical criteria of cardiogenic shock. The Class 1 recommendation is that in patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and maintain end-organ performance (LOE B-NR). Their broad availability, ease of administration, and clinician familiarity favor such agents as first line when signs of hypoperfusion persist. Interestingly, despite their ubiquitous use for management of cardiogenic shock, there is a lack of robust evidence to suggest the clear benefit of one agent over another.\xa0 Therefore, the choice of a specific agent is guided by additional factors including vital signs, concurrent arrhythmias, and availability. For this patient, dobutamine is the only inotrope listed. Although she is tachycardic, her lack of arrhythmia makes dobutamine relatively lower risk and does not outweigh the potential benefits.\n\nChoice A \u2013 Increase carvedilol \u2013 is not correct. Beta-blockers should be continued in HF hospitalization whenever possible; however, in a patient with low cardiac output and signs of shock, beta-blockers should be discontinued due to their negative inotropic effects.\n\nChoice C \u2013 Increase lisinopril \u2013 is not correct. Afterload reduction is reasonable to decrease myocardial oxygen demand. However, given the hypotension and renal dysfunction, increasing lisinopril could be potentially dangerous by fur...