In a patient with volume overload and new onset HFrEF, the first step in management is?

• A. Treat the overload with furosemide and ACE inhibitors before reassessing the need for beta blockers
• B. Start a Beta-Blocker Immediately
• C. Initiate an ARB Only
• D. Observation Without Therapy

Answer: (A)

When someone has heart failure with reduced ejection fraction and is volume overloaded, the immediate goal is to relieve congestion and stabilize hemodynamics before adding further disease-modifying therapies. The fastest way to do that is to use a loop diuretic to unload excess fluid, which rapidly improves dyspnea and edema. At the same time, starting an ACE inhibitor helps reduce afterload and favorable remodeling, improving long-term outcomes. Beta-blockers, while they reduce mortality in HFrEF, can blunt the heart’s response during acute decompensation or volume overload, so they’re best added after the patient is euvolemic and clinically stable. If an ACE inhibitor isn’t tolerated, an ARB can be used, but it isn’t the preferred first step in this scenario. Observing without therapy would miss the opportunity to relieve congestion and begin life-extending neurohormonal blockade.