Clinical Twisters: Treating acute heart failure

A 70-year-old Caucasian man, N.B., presents to your emergency department with dyspnea, peripheral edema, and weight gain. He had a myocardial infarction five years ago and has progressive congestive heart failure (HF) (NYHA Class IV stage D). Currently, BP = 90/60, HR = 78, labs normal except BUN = 48, SrCr = 2 mg/dl, B-type natriuretic peptide = 1100 pg/ml. Physical assessment shows bilateral rales and warm and wet skin turgor. Current medications: furosemide 40 mg q.d., ramipril (Altace, Aventis) 2.5 mg q.d., carvedilol (Coreg, GlaxoSmithKline) 12.5 mg b.i.d., metolazone 2.5 mg p.r.n., weight gain (not taken last month). To treat his acutely decompensated HF and pulmonary edema, his physician prescribes furosemide 40 mg IV x 1. She asks whether to add nesiritide (Natrecor, Scios) or nitroglycerin (NTG) infusion.