American Board of Internal Medicine (ABIM) Certification Practice Exam

What is a primary indication for initiating spironolactone in heart failure management?

1. NYHA Class I heart failure

2. NYHA Class II-IV and LVEF ≤ 35%

3. Asymptomatic patients with preserved ejection fraction

4. Uncontrolled hypertension

The correct answer is: NYHA Class II-IV and LVEF ≤ 35%

Initiating spironolactone in heart failure management is primarily indicated for patients who are in New York Heart Association (NYHA) Class II to IV and have a left ventricular ejection fraction (LVEF) of 35% or less. This is based on evidence from clinical studies indicating that spironolactone, a potassium-sparing diuretic and aldosterone antagonist, significantly improves outcomes in this patient population. Patients with moderate to severe heart failure (NYHA Class II-IV) often have increased levels of aldosterone, which contributes to fluid retention, increased cardiac workload, and detrimental cardiac remodeling. By blocking the effects of aldosterone, spironolactone helps to reduce fluid overload, improve symptoms, and lower mortality rates in these patients. The other scenarios presented do not align with the primary clinical indications for spironolactone therapy. For instance, patients classified as NYHA Class I typically do not require spironolactone since their heart failure is less symptomatic and less severe. Asymptomatic patients with preserved ejection fraction are not indicated for spironolactone, as the medication is most beneficial for those with reduced ejection fraction. Uncontrolled hypertension may be treated with spironolactone