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J Card Fail. 2004 Jun;10(3):210-8.

Searching for evidence: Refractory questions in advanced heart failure.

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Duke Clinical Research Institute, Durham, North Carolina 27715, USA.



Despite ample data from randomized clinical trials (RCTs), the management of advanced heart failure (HF) varies greatly. We examined the most common refractory questions arising in routine inpatient management of advanced HF.


From the inpatient HF service at 1 hospital, we prospectively recorded clinical questions arising for which there were no clear answers available about HF management. When possible, patients received angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and spironolactone as used in RCTs. We identified the topics and frequencies of questions and categorized them as Group 1--whether to use a therapy--or Group 2--how to use a therapy.


During 2 separate months, 318 questions arose among 57 patients. The most common topics involved the use of diuretics, potassium, and ACE inhibitors, most often about how to titrate diuretics, what targets to use to optimize diuretic therapy, and how to select discharge doses of diuretics. Questions of whether to use a therapy occurred 73 times, and how to use a therapy, 242 times. RCT data were difficult to apply to these questions because little information exists about how to combine and titrate HF drugs and how to adjust diuretics. Questions about individual drugs arose in patients who fell outside the average RCT entry criteria for age, blood pressure, and creatinine.


Most refractory questions focused on how to integrate and adjust therapies within the overall medical regimen and how to apply data to patients not represented in RCTs. Future studies should evaluate strategies of care for the advanced HF population.

[Indexed for MEDLINE]

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