Investigation and management of congestive heart failure

Arrol and colleagues’ review of the management of congestive heart
failure (HF) [1] disregards much of the significant progress that has been
made since the previous review of this topic was published in BMJ in 2002
[2]. Concentration on more established pharmacotherapy is somewhat at the
expense of groundbreaking developments occurring over the intervening
period which include:

Demonstration of the benefits of angiotensin II receptor blockade in
low ejection fraction heart failure patients either already taking [3] or
intolerant of [4] an ACE inhibitor.

The now major contemporary role of cardiac resynchronisation therapy
which has been shown to improve morbidity and mortality in patients with
both advanced [5,6] and, more recently, milder symptoms [7].

The emergence of ventricular assist devices as a life changing
treatment option in selected patients with end-stage HF [8].

Despite advances in therapy, morbidity and mortality in HF remain
high. It is therefore crucial that significant advances are relayed
promptly and accurately to generalists/non-HF specialists involved in the
management of HF who decide upon the appropriateness of, potentially
crucial, onward specialist referral.

References

[1] Arroll B, Doughty R, Andersen V. Investigation and management of
congestive heart failure. BMJ. 2010;341:c3657.

[2] Cowie MR, Zaphiriou A. Management of chronic heart failure. BMJ.
2002;325:422-5.

[3] McMurray JJ, Ostergren J, Swedberg K, Granger CB, Held P,
Michelson EL et al; CHARM Investigators and Committees. Effects of
candesartan in patients with chronic heart failure and reduced left-
ventricular systolic function taking angiotensin-converting-enzyme
inhibitors: the CHARM-Added trial. Lancet. 2003;362:767-71.

[4] Granger CB, McMurray JJ, Yusuf S, Held P, Michelson EL, Olofsson
B et al; CHARM Investigators and Committees. Effects of candesartan in
patients with chronic heart failure and reduced left-ventricular systolic
function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM
-Alternative trial. Lancet. 2003;362:772-6.

[5] Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D,
Kappenberger L et al; Cardiac Resynchronization-Heart Failure (CARE-HF)
Study Investigators. The effect of cardiac resynchronization on morbidity
and mortality in heart failure. N Engl J Med. 2005;352:1539-49.

[6] Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T
et al; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart
Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with
or without an implantable defibrillator in advanced chronic heart failure.
N Engl J Med. 2004;350:2140-50.

[7] Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP et al;
MADIT-CRT Trial Investigators. Cardiac-resynchronization therapy for the
prevention of heart-failure events. N Engl J Med. 2009;361:1329-38.

[8] Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman
D et al; HeartMate II Investigators. Advanced heart failure treated with
continuous-flow left ventricular assist device. N Engl J Med.
2009;361:2241-51.

Competing interests:
None declared