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The differential diagnosis for a 65-year-old woman with heart failure is discussed in the setting of a clinicopathological conference at Louisiana State University Medical Center in Shreveport. The discussion includes precipitating factors, pathophysiology, and etiologies of heart failure.

Heart failure is a major and growing public health problem in the United States. Hospitalization and death for heart failure have risen dramatically and the proportion of women with heart failure, especially older women, is projected to be the predominant group in the next 3 decades. There is growing evidence that the etiology, pathophysiology, prognosis, and response to treatment may all be different in women. In addition, there is evidence that hypertension plays a more prominent role and that preserved left ventricular systolic function is more likely to be found in women. There are legitimate questions about the degree of benefit that women receive from standard medications. A major obstacle in our understanding of heart failure in women has been their underrepresentation in major clinical trials. Current emphasis on ensuring adequate representation in clinical trials should help to further our understanding of heart failure in women and its management.

Randomized clinical trails have demonstrated that angiotensin-converting enzyme (ACE) inhibitors reduce mortality, improve symptoms, and decrease hospitalization rates in congestive heart failure (CHF) patients with impaired left ventricular systolic function. Guidelines from the Agency for Healthcare Policy and Research (AHCPR) endorse the use of ACE inhibitors in eligible CHF patients and note their underutilization in practice. Randomly selected records of 1,212 Medicare CHF patients in Louisiana, discharged between July 1993 and October 1993, were reviewed. Abstracted data were used to characterize practice patterns and pertinent clinical factors influencing current ACE inhibitor utilization by practicing physicians in eligible Medicare CHF patients admitted to acute care hospitals. A total of 1,133 patients admitted were discharged alive; mean age was 77.6 years (64% female; 68% white). One third of the patients (34%) were already receiving ACE inhibitors on admission; of these, 85% were discharged on ACE inhibitors. The remaining 66% of patients were not on an ACE inhibitor on admission; only 35% of these are documented to have been placed on an ACE inhibitor(s) at discharge. Overall, a significantly large number of CHF patient charts (48%) lacked documentation of LV systolic function assessments. On multivariate logistic regression modeling, the following key clinical variables were positively related to the prescription of ACE inhibitors: low ejection fraction, dyspnea and orthopnea, normal creatinine levels, high diastolic blood pressure, cardiomegaly, and increasing age. Among patients with low ejection fraction, factors contributing to not being discharged on ACE inhibitors included: high creatinine levels, history of myocardial infarction or ischemic heart disease, renal failure, and being African American. This study documents the underutilization of ACE inhibitors in patients with impaired left ventricular systolic function. Results suggest the need for increased physician-based educational efforts concerning the use of ACE inhibitors in CHF patients, and also for increasing left ventricular systolic function assessments and documentation of findings in patient charts.

Heart failure is a major and increasing public health problem. Coronary artery disease has become the major etiology of heart failure. The differentiation of viable from nonviable myocardium in patients with coronary disease and impaired left ventricular systolic function is an issue of extreme importance to the clinician. Several diagnostic modalities including thallium imaging, dobutamine stress echocardiography, and positron emission tomography have gained considerable acceptance as useful tools in detecting myocardial viability. The management of heart failure with preserved left ventricular systolic function includes the use of beta blockers, calcium channel blockers, and nitrates. In patients with heart failure and impaired left ventricular systolic function, angiotensin converting enzyme inhibitors have become an integral part of the medical management. In patients whose angina is unresponsive to the addition of nitrates, a trial of bet blockers should be attempted and first generation calcium blockers should be avoided. Revascularization should always be sought, particularly when myocardial viability has been established.