Drug treatment in heart failure

doi:10.1136/bmj.320.7243.1188

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Eva Lonn, associate professor of medicine (lonnem@fhs.McMaster.ca),
Robert McKelvie

Hamilton Health Sciences Corporation, General Site, McMaster Clinic, Hamilton, Ontario L8L 2X2, Canada

Correspondence to: E Lonn

Heart failure represents a complex clinical syndrome characterised by abnormalities of left ventricular function and neurohormonal regulation, exercise intolerance, shortness of breath, fluid retention, and reduced longevity.1 Despite improvements in treatment the prognosis for patients with heart failure remains poor: the risk of death annually is 5%-10% in patients with mild symptoms and 30%-40% in those with advanced disease.2 3 This condition is also associated with major morbidity and healthcare expenditure, being responsible for about 5% of hospital admissions in the United Kingdom.4

Box 1: Treatment of heart failure

Aims

Relief of symptoms
Improvement in quality of life
Prevention of admissions to hospital, recurrent ischaemic events, and further deterioration in left ventricular function
Reduction in mortality

Treatment modalities

Non-pharmacological treatments, such as exercise rehabilitation, dietary and psychological interventions, and patient education including self care strategies
Non-pharmacological treatments, such as exercise rehabilitation, dietary and psychological interventions, and patient education including self care strategies
Surgical and device based interventions

Mitral valve surgery

Coronary revascularisation

Surgical ventricular remodelling procedures

Cardiomyoplasty

Dual chamber pacing

Implantable cardioverter defibrillator treatment

Ventricular assist devices

Artificial heart

Heart transplantation

This review deals only with pharmacological treatments in chronic heart failure. Non-pharmacological measures apply to all patients, whereas surgical and device treatments (many still experimental) apply only to specific patient subsets. Patients with clinical symptoms of heart failure but normal or near normal left ventricular systolic function often have impaired left ventricular diastolic function. This heterogeneous group has been generally excluded from heart failure trials. We do not discuss the treatment of diastolic left ventricular dysfunction or acute heart failure syndromes: more comprehensive reviews are available.5