PLAB Question 13

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) warfarin
e) calcium supplements
f) vitamin K
g) verapamil
h) beta blockers
i) digitalis
j) amiloride








ANSWER
The correct answer is C



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 that 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.

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