Pseudo-Intractable Heart Failure With Edema: Some of the Mechanisms and Means for Restoring Response to Treatment

¹ Cornell University Medical College; the Hospital for Joint Diseases and Medical Center; Beth Israel Medical Center, New York, N.Y.
² Cornell University Medical College; the Hospital for Joint Diseases and Medical Center; Beth Israel Medical Center, New York, N.Y.

Pseudo-intractable heart failure is distinguished from true intractable heart failure by the fact that, while both develop resistance to treatment by the conventional measures, the former yields to one or another regimen of treatment, the latter yields to none and is due to factors that are irreversible.

We have described a variety of cases of pseudo-intractable failure and the methods by which the apparently intractable failure is reversed.

A regimen including a salt-restricted diet in the form of 3 liters of milk and water in equal amounts, digitalization, and a daily injection of 2 cc meralluride or mercaptomerin reverses the vast majority of cases of so-called pseudo-in-tractable failure.

The two types of failure can usually be distinguished in a few days by the response to a therapeutic trial of the new diuretic regimen. If a weight loss occurs 24 hours after the first or second daily 2-cc injection of the mercurial, the patient is one of reversible or pseudo-in-tractability. If in the absence of a manifest obstacle, the patient fails in this challenge, the case is one of true, or irreversible, intractable failure not likely to yield to any form of antifailure treatment.

Pressure from massive ascites can impair the renal circulation and make a pseudo-intractable failure react like true irreversible intractability. Abdominal paracentesis can restore the response to the mercurial diuretic.

Surreptitious salt intake is a pitfall in the human pharmacology of diuresis. Pseudo-intractable (reversible) failure can assume thereby the behavior pattern of true (irreversible) intractable failure.

Response to a diuretic agent has a diphasic pattern, a diuretic response associated with an antidiuretic reaction. A patient with edema, very sensitive to the diuretic action, and with a dominant antidiuretic reaction, may disclose the paradox of little or no clearing of edema in one with vigorous reactions to individual doses of the diuretic.

A series of similar daily doses of a diuretic, however short, shows declining diuretic responses even in the presence of abundant edema. In a very sensitive patient, even one dose causing a massive diuresis may be followed by suppression of response to subsequent daily doses. We assume these phenomena to be due to adrenal antidiuretie factors.

The decline or suppression of the diuretic response to a previous dose of the diuretic can be prevented by oral doses of spirolactone (Aldactone) and sometimes by other steroids.

Digitalis does not reverse pseudo-intractable heart failure since these patients are usually already fully digitalized.

A daily intramuscular dose of the organic mercurial is very effective in establishing response in pseudo-intractable failure. Several oral nonmercurials have been developed recently, some of considerable efficacy. It remains for clinical trial to determine whether they can take the place of the injectable mercurial in restoring response in cases of pseudo-intractable heart failure.

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