Refractory Heart Failure

Patients with cardiac decompensation who fail to respond satisfactorily to routine therapeutic measures are generally categorized as having refractory heart failure. Among the multiple pathophysiologic mechanisms involved are disturbed myocardial function, diminished cardiac output, decreased renal hemodynamic functions, and aldosteronism.1 From a diagnostic standpoint, it should be remembered that obesity, phlebitis, anemia, and hypoproteinemia, as well as renal, pulmonary, and hepatic diseases, may closely resemble the cardinal signs and symptoms of cardiac failure. Therapeutically, it is noteworthy that patients with refractory heart failure not infrequently have associated conditions which, when corrected, result in improved cardiac status.2 Remediable Extracardiac Conditions Remediable extracardiac conditions may include inadequate restriction of physical activity or salt intake, or both. Inadequate dosage of digitalis can also contribute to refractory heart failure. Although toxic reactions to digitalis are prone to develop in patients with severe cardiac decompensation, it may nonetheless be helpful to increase digitalis