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Answer 1
  1. Initiation of IV furosemide without nitroglycerine, with accurate monitoring off weight and urine output; readminister diuretic only if there are persistent findings of volume overload. The patient has acute decompensated heart failure related to sever aortic stenosis. This condition requires careful diuresis to relieve pulmonary edema and volume overload with close attention to the patient’s volume status. Overaggressive reduction of preload (through aggressive diuresis and/or nitrates) can result in marked hemodynamic instability given the limited capacity of the heart to augment cardiac output due to the stenotic valve.1 Given the clinical picture, neither a BNP level nor an urgent echocardiogram is likely to alter the clinical management of the patient at this point. Small ST-segment and T-wave changes are nonspecific in the setting of LV hypertrophy and tachycardia and must be interpreted in the larger clinical context.

    1. Hunt SA, Abraham WT, Chin MH, et al 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2009 14;53:el–90.

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