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Current and novel pharmacologic approaches in advanced heart failure

1999; Elsevier BV; Volume: 28; Issue: 4 Linguagem: Inglês

10.1016/s0147-9563(99)70069-5

1527-3288

Christopher M. O’Connor, Wendy A. Gattis, Karl Swedberg,

Potassium and Related Disorders

In spite of intense investigation of novel heart failure pharmacotherapy, clinicians are still limited to traditional therapy for advanced heart failure. Although the impact of angiotensinconverting enzyme (ACE) inhibitors on heart failure-related mortality has clearly been demonstrated, 1 The CONSENSUS Trial Study Group Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study. N Engl J Med. 1987; 316: 1429-1435 Crossref PubMed Google Scholar , 2 The SOLVD Investigators Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991; 325: 293-302 Crossref PubMed Google Scholar , 3 The SOLVD Investigators Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med. 1992; 327: 685-691 Crossref PubMed Google Scholar , 4 Cohn JN Johnson G Ziesche S Cobb F Francis G Tristani F et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991; 325: 303-310 Crossref PubMed Google Scholar , 5 Pfeffer MA Braunwald E Moye LA Basta L Brown EJ Cuddy TE et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement Trial. N Engl J Med. 1992; 327: 669-677 Crossref PubMed Google Scholar , 6 The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet. 1993; 342: 821-828 Abstract PubMed Google Scholar , 7 Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico GISSI-3: effect of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet. 1994; 343: 1115-1122 PubMed Google Scholar , 8 Ambrosioni E Borghi C Magnani B. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. N Engl J Med. 1995; 332: 80-85 Crossref PubMed Scopus (583) Google Scholar , 9 Køber L Torp-Pedersen C Carlsen JE Bagger H Eliasen P Lyngborg K et al. A clinical trial of the angiotensin-converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 1995; 333: 1670-1676 Crossref PubMed Scopus (1280) Google Scholar the 5-year mortality rate of 50% remains unacceptably high. 10 Centers for Disease Control and Prevention Mortality from congestive heart failure – United States, 1980-1990. MMWR. 1994; 43: 77-81 PubMed Google Scholar Based on current Agency for Health Care Policy and Research, American College of Cardiology/American Heart Association, and European Society of Cardiology guidelines for the treatment of patients with heart failure, 11 Heart Failure Evaluation and care of patients with left ventricular systolic dysfunction. Clinical practice guideline number II. June 1994 Google Scholar , 12 American College of Cardiology/American Heart Association Guidelines for the evaluation and management of heart failure. J Am Coll Cardiol. 1995; 26: 1376-1398 Abstract Full Text PDF PubMed Google Scholar , 13 The Task Force on Heart Failure of the European Society of Cardiology Guidelines for the diagnosis of heart failure. Eur Heart J. 1995; 16: 741-751 PubMed Google Scholar ACE inhibitors should be instituted for any patient with a left ventricular ejection fraction (LVEF) <40%, provided the patient has no absolute contraindications to ACE inhibitors, specifically angioedema or bilateral renal artery stenosis. Diuretics should be added if the patient also has symptoms of fluid retention or volume overload. Digoxin is recommended in patients who have symptoms despite undergoing optimal treatment with ACE inhibitors and diuretics (Table I). Table ICurrent accepted strategies for the treatment of patients with heart failure Agent Patient population ACE inhibitors All patients with LVEF <40% regardless of symptoms unless contraindications (bilateral renal artery stenosis, angioede ma) exist. Hydralazine and nitrates combined Patients who have absolute contraindications to ACE inhibitors or in patients intolerant to ACE inhibitors. Diuretics Patients with symptoms of congestion or volume overload. Digoxin Patients with persistent symptoms despite treatment with ACE inhibitors and diuretics. Beta blockers Patients with mild to moderate heart failure. Open table in a new tab