Circulation, Vol 88, 2941-2952, Copyright © 1993 by American Heart Association
PW Armstrong and GW Moe
The increased incidence and prevalence of congestive heart failure place a
high priority on novel treatment strategies. Left ventricular ejection
fraction remains the single most valuable measurement providing both
diagnostic and prognostic insights. The most systematic approach to heart
failure involves an objective assessment of functional disability, to
include exercise tests such as a 6-minute walk under standardized
conditions. Left ventricular dysfunction incites a host of neurohumoral
compensations that are of fundamental importance in the heart failure
syndrome expression. Both vasoconstrictor and vasodilator neurohormones are
stimulated and provide new therapeutic opportunities. The therapeutic
approach to heart failure begins with a strong emphasis on prevention,
patient education, and self-participation in therapy with respect to both
its monitoring and adjustment. Diuretics remain a mainstay of therapy but,
in the face of severe heart failure, may become ineffectual, requiring
constant infusion of loop-active diuretics, combination diuretics, or
diuretics in association with concomitant low-dose dopamine infusion.
Vasodilator therapy has been an important advance: combination hydralazine
and nitrate therapy was initially shown to be efficacious in improving
survival, and more recently, angiotensin-converting enzyme (ACE)
inhibitors, in the form of enalapril, have shown incremental benefit on
survival over this combination. Interestingly, there is now evidence from
both SOLVD and SAVE to demonstrate an unexpected and, as yet, unexplained
reduction in the frequency of both unstable angina and myocardial
infarction. Although, on balance, the weight of evidence concerning the
long-term efficacy of inotropic agents has been disappointing, especially
as it relates to their unfavorable effects on survival, recent information
on vesnarinone, an agent with a complex and diversified mechanism of
action, suggests that with appropriate doses, improved symptoms and
survival are possible. A substantial amount of new information from
randomized placebo-controlled trials attests to the symptomatic relief,
hemodynamic improvement, and gain in exercise performance achieved by
digoxin. A long-term survival study is ongoing to assess its effects on
mortality. beta-Blockers, especially metoprolol, appear beneficial in some
patients with heart failure, possibly related to their reduction in
sympathetic nervous activity and restoration of beta-receptor population,
with resultant improved contractile performance, enhanced myocardial
relaxation, and overall increase in cardiac efficiency. Based on available
evidence, the best contemporary approach to treatment involves the use of
ACE inhibitors coupled with diuretic therapy, either continuous or
intermittent, to relieve central or peripheral congestion. The addition of
digoxin or a hydralazine nitrate combination is a logical next step, with
commencement of low-dose beta-blocker a reasonable option.(ABSTRACT
TRUNCATED AT 400 WORDS)
ARTICLES
Medical advances in the treatment of congestive heart failure
Department of Medicine, St Michael's Hospital, University of Toronto, Canada.
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