Q&A: Treatment of Heart Failure

Heart failure (HF) is a common clinical syndrome in which symptoms result from a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders.

This article is for Medical Students & Professionals

This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Cardiovascular Diseases article more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.

In this article:
Categorization of heart failure
MCQ: clinical scenario
MCQ: answer
MCQ: explanation

Categorization of heart failure

As mentioned earlier, heart failure (HF) may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders. HF due to left ventricular (LV) dysfunction is categorized according to LV ejection fraction (LVEF) into HF with reduced ejection fraction (with LVEF ≤40 percent, known as HFrEF; also referred to as systolic HF), HF with preserved ejection fraction (with LVEF ≥50 percent; known as HFpEF; also referred to as diastolic HF), and HF with mid-range ejection fraction (with LVEF 41 to 49 percent; known as HFmrEF).

The goals of therapy of HFrEF are to reduce morbidity (ie, reduce symptoms, improve health-related quality of life and functional status, and decrease the rate of hospitalization), and to reduce mortality.

MCQ: clinical scenario

An elderly woman with known congestive heart failure presents with severe dyspnea at rest.

The most appropriate treatment at this stage would be:

a) Hydrochlorothiazide
b) Captopril
c) A loop diuretic
d) Beta blockers
e) Digitalis
f) Amiloride

MCQ: answer

The correct answer is C

MCQ: explanation

If it is judged reasonable to attempt outpatient management of such patients, a loop diuretic such as furosemide or ethacrynic acid is necessary. Small doses of loop diuretics may also benefit patients with mild to moderate failure who cannot be adequately controlled by thiazides. Patients with more severe CHF, manifested by dyspnea at rest, orthopnea, or paroxysmal nocturnal dyspnea, represent the other end of the spectrum.

Caution is warranted when treating a patient for the first time with a loop diuretic, because a marked diuresis may be evoked, even from a small dose. If a thiazide had been used previously, it should be stopped rather than continued in conjunction with the loop diuretic, because the two agents are very potent when used together. The combination of a thiazide and loop diuretic is indicated in cases of failure refractory to large doses of the loop diuretic alone. The maximal effect of a loop diuretic can be achieved by using a large single daily dose, rather than smaller doses spread throughout the day.

Reference(s)
1). UpToDate: Overview of the management of heart failure with reduced ejection fraction in adults. Available online: https://www.uptodate.com/contents/overview-of-the-management-of-heart-failure-with-reduced-ejection-fraction-in-adults