Chief Complaint  Chief Complaint: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, bilateral lower extremity edema  Onset: 1 week before admission  The patient reports worsening shortness of breath over the past week, preventing her from walking more than a few steps without needing to stop and catch her breath.  She also endorses orthopnea and paroxysmal nocturnal dyspnea, requiring her to sleep sitting up using multiple pillows.  Additionally, significant bilateral pitting edema is noted up to her legs History of Present Illness  Additional history: The patient was diagnosed with systolic heart failure one year ago after an MI.  Since then, her heart failure has been managed as an outpatient on guidelinedirected medical therapy.  Over the past week, she reports worsening dyspnea on exertion, orthopnea, and edema suggestive of an acute exacerbation of her chronic systolic heart failure.  Of note, the patient recently missed several doses of her heart failure medications due to the inability to refill them on time. Past Medical History  Past medical history: Chronic systolic heart failure (LVEF 30%), hypertension, diabetes mellitus type 2, chronic kidney disease stage 3.  Past surgical history: None Medications and Social History  Medications: o Furosemide 40 mg PO daily o Metoprolol succinate 50 mg PO daily o Lisinopril 10 mg PO daily o Aspirin 81 mg PO daily  Social history: Retired teacher, smoking history (quit 10 years ago), consumes 1-2 alcoholic beverages per week.  Widowed, lives alone with home health assistance due to difficulties with ADLs from heart failure symptoms. Vital Signs and Physical Exam Findings  Vital signs: T: 37 C P: 112 bpm irregularly BP: 172/92 mmHg RR: 21 bpm SpO2:97% on room air  Physical exam: Pleasant female, speaking in full sentences.  Lung exam with bilateral rales mid to lower zones, 2 bilateral pitting edema. Diagnostic Results  Initial diagnostics: o BNP: 1230 pg/mL o Troponin: 0.05 ng/mL  CXR: Pulmonary vascular congestion, small bilateral pleural effusions  EKG: Atrial fibrillation, left bundle branch block, ST depressions suggestive of left ventricular hypertrophy Assessment and Plan  Assessment: o Acute on chronic systolic heart failure exacerbation o Differential diagnosis: MI, COPD exacerbation, pneumonia  Treatment recommendations: o IV diuresis with furosemide drip, consider ultrafiltration o Rate control medications o Reinitiate GDMT titration o Consider AICD/CRT given LBBB Epidemiology  Over 6 million adults in the US have CHF, with incidence approaching 10 per 1000 in those over 65 years old.  Annual mortality rates approach 50% in those with severe symptoms.  The total cost of CHF care is estimated at over $30 billion annually. Pathophysiology  In chronic systolic heart failure, reduced LVEF leads to decreased cardiac output.  Complex syndrome that results from any functional impairment of ventricular filling or ejection of blood.  Exacerbating factors like medication/ dietary noncompliance can acutely worsen hemodynamic status. Evidence-Based Treatment  GDMT medications, including ACEi/ARBs, beta-blockers, and Aldosterone receptor antagonists, have grade recommendations for reducing mortality and rehospitalization (Abe et al., 2020).  Ultrafiltration has recommendation for acute fluid removal compared to IV diuresis alone in ADHF. References  Abe, T., Jujo, K., Kametani, M., Minami, Y., Fukushima, N., Saito, K.,