What is not true about medication management in heart failure: A) Furosemide (Lasix) does not decrease mortality, B) Spironolactone (Aldactone) decreases mortality by 30-35% as shown in the RALES study, C) Angiotensin-Converting Enzyme inhibitors (ACE-i) significantly decrease mortality, or D) maximizing the dose of Beta-Blockers (BB) is recommended in patients over 70 years old?

What is NOT True About Medication Management in Heart Failure

The statement that is NOT true is Option D: maximizing the dose of beta-blockers in patients over 70 years old is NOT universally recommended—rather, elderly patients should be titrated carefully to target heart rate (55-64 bpm) or tolerated doses, not necessarily maximum doses. 1, 2, 3

Analysis of Each Statement

A) Furosemide Does Not Decrease Mortality - TRUE Statement

• Loop diuretics like furosemide are used for symptomatic relief of congestion but have no proven mortality benefit 4
• Diuretics are first-line for relieving volume overload but do not prevent disease progression 4
• This statement is factually correct

B) Spironolactone Decreases Mortality by 30-35% in RALES - TRUE Statement

• The RALES trial demonstrated that low-dose spironolactone (12.5-50 mg daily) reduced mortality by 30-34% in NYHA class III-IV heart failure patients 4, 5
• This benefit was consistent when added to ACE inhibitor and diuretic therapy 4, 5
• The FDA label confirms this 30% mortality reduction (p<0.001) 5
• This statement is factually correct (the 35% cited in the question is within the range of reported benefits)

C) ACE Inhibitors Significantly Decrease Mortality - TRUE Statement

• ACE inhibitors are cornerstone therapy with proven mortality benefit in heart failure 4, 1
• They reduce mortality across all stages of heart failure and are recommended as standard therapy 4
• This statement is factually correct

D) Maximize Beta-Blocker Dose in Patients Over 70 Years - FALSE Statement

This is the incorrect statement for several critical reasons:

Evidence Against Dose Maximization in Elderly

• Target heart rate, not maximum dose, is the appropriate goal in elderly heart failure patients 3
• The CIBIS-ELD trial specifically demonstrated that achieved heart rate after titration (55-64 bpm), not the beta-blocker dose itself, predicted mortality in elderly patients 3
• Achieved beta-blocker dose was NOT associated with mortality risk in elderly patients 3

Appropriate Approach in Elderly Patients

• Start low and titrate slowly: Initial dose should be as low as possible (1.25 mg/day for bisoprolol), with dose increases longer than 15 days if necessary 2
• The objective is to reach the target dose if tolerated, but this must be done progressively with careful monitoring 2
• In the SENIORS trial of patients ≥70 years, the mean maintenance dose achieved was only 7.7 mg of nebivolol (target 10 mg), yet significant benefit was still demonstrated 6

Age-Specific Considerations

• Adverse effects may be both more frequent and more serious in elderly patients, requiring strict adherence to titration protocols 2
• Age alone should not preclude beta-blocker use, but elderly patients require more cautious titration 4, 1
• The evidence shows elderly patients gain similar benefit to younger patients, but maximizing dose is not the goal—achieving optimal heart rate control is 4, 2, 3

Clinical Pitfalls to Avoid

Common Error: Assuming higher doses always equal better outcomes in elderly patients. The evidence clearly shows that in patients over 70, heart rate control (55-64 bpm) is more predictive of mortality benefit than achieving maximum labeled doses 3

Practical Approach: Titrate beta-blockers slowly in elderly heart failure patients, monitoring for symptomatic hypotension, bradycardia, and heart failure decompensation, with the goal of achieving a resting heart rate of 55-64 bpm rather than a specific maximum dose 2, 3