"The failing heart is not just an enlarged version of a normal heart." I know Dr. Louis Katz said it, but I never found out where. At any rate, he posthumously alerted me to recognize that patients with heart failure do not demonstrate the lower range of normal physiology, but rather their own special ranges. I recognize this in the exquisite load sensitivity of the failing heart or in noting how much atrioventricular synchrony contributes to the failing heart. I try to teach this all the time-I'll know it's time to retire when I overhear the medical students joking about me having them graph the relationship between cardiac output and vascular resistance. Nevertheless, it's a concept I use every day.-Marc A. Silver Similar to all disease states, the primary approach to and ultimate treatment of heart failure is prevention. For the entire human population, this means bringing systemic blood pressure into the currently recommended range, controlling the risk factors for atherosclerosis, aggressively managing ischemic syndromes, reversing valvular and congenital lesions before cardiac damage occurs, and so forth. Hopefully, over time, we'll be able to counter and reverse many of the predisposing genetic factors as well.-Carl V. Leier Ask patients to describe exactly how they take their medications. Heart failure patients are frequent victims of polypharmacy, and despite the best intentions of the health care providers and patients, inadvertent medication errors are common. For example, one of my patients mixed up his digoxin and isosorbide dinitrate; as a result, he was taking digoxin three times a day (and wondering why he was nauseated)! Ask routinely about the use of over-the-counter medications, especially cold preparations, "diet pills," and nonsteroidal anti-inflammatory drugs (NSAIDs). These widely available agents are frequently used by heart failure patients, who fail to recognize the potential for drug-drug and drug-disease interactions.-Michael W. RichThere are several things I routinely do for each patient who comes to see me. On the first visit, I examine current medications and simplify the regimen. I eliminate calcium channel blockers, NSAIDs, and albuterol (unless there is a pressing need to continue these). We routinely check digoxin levels and adjust the medication to keep the plasma level between 0.7 and 1.0 ng/mL. This is based on data from our laboratory showing that most of the benefit of this drug is at low dose (J Am Coll Cardiol. 1997;29:1206) and a post hoc analysis of the DIG study, which showed a relationship of plasma level and mortality with more toxicity at higher doses (Am Heart J. 1997;134:3). I optimize angiotensin-converting enzyme (ACE) inhibitor doses (in an attempt to use the doses shown to be efficacious in the clinical trials) and use a longer-acting, preferably once-a-day ACE inhibitor to simplify the patient's regimen. I often give this dose prior to bedtime so that any hypotension will be at night while the patient is sleeping. I also give nitrates to my heart failure pat...