In the scenario described, the 69-year-old man with refractory congestive heart failure presents with dyspnea, severe pulmonary and peripheral edema, and hypotension (blood pressure of 86/40 mm Hg). This indicates that he is in a state of compromised cardiac output and is likely experiencing cardiogenic shock.
Given these circumstances, the most appropriate medication to administer is C. Dobutamine. Dobutamine is an inotropic agent that increases cardiac output by stimulating beta-1 adrenergic receptors, which enhances myocardial contractility. This is particularly useful in patients with heart failure and low blood pressure, as it can help improve perfusion without significantly increasing systemic vascular resistance.
The other options are less appropriate for this situation:
- A. Clonidine: An alpha-2 agonist that reduces sympathetic outflow, it would not be suitable for a patient in shock.
- B. Albuterol: A bronchodilator used primarily for asthma or COPD exacerbations, not for treating heart failure or shock.
- D. Low-dose dopamine: While it can increase renal perfusion and has some inotropic effects, dobutamine is generally preferred in acute heart failure with shock settings.
- E. Phenylephrine: A pure alpha-1 agonist that increases systemic vascular resistance and may worsen cardiac output in a patient with heart failure.
Thus, in this clinical scenario, dobutamine is the best choice.