Summary
Congestive heart failure is a lethal condition that affects an increasing number of patients. In recent years a great amount of data have accumulated on the pathophysiology and medical and surgical therapy of this condition. In spite of the advances in its management and the great number of patients affected, common errors are still made by internists and cardiologists in the use of drugs and therapeutic strategies. Digitalis has only recently been shown to affect hemodynamics, exercise capacity, and clinical symptoms, but the effects on survival still have to be demonstrated. Loop diuretics, eventually combined with thiazides and antialdosterone drugs in patients with clinical signs and symptoms of fluid retention, are the mainstays of therapy of congestive heart failure. In order to make diuretic therapy efficacious, moderate salt and water intake restriction is mandatory. Angiotensin-converting enzyme (ACE) inhibitors are now considered unavoidable drugs in the management of heart failure, and an attempt to reach the doses that have been shown to be efficacious for survival in the large trials has to be made in every patient with this condition. Other vasodilators, such as hydralazine and nitrates, which show a less pronounced effect on survival but more effective hemodynamic actions than ACE inhibitors, may be used to control mitral insufficiency or to improve hemodynamics in very sick patients. Hemodynamic instability refractory to increasing doses of vasodilators and diuretics is a severe condition that requires hospital admission to administer drugs parenterally. These patients are usually treated with the combination of catecholamines and phosphodiesterase inhibitors associated with intravenous diuretics until clinical stability is again achieved and oral therapy is resumed and restructured. The use of aggressive pharmacological therapy and phosphodiesterase inhibitors has reduced the need for assisted circulatory support in these patients. Beta-blockers have shown promising results when administered to patients with heart failure, although a definitive demonstration of their effects on survival is still lacking. Other additional measures that need to be considered in patients with end-stage congestive heart failure are the use of antiarrhythmic drugs and anticoagulation.
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References
Cohn, JN. Who should treat cardiac failure? J Cardiac Failure 1995;1:97.
Kaye, MP. The Registry of the International Society for Heart and Lung Transplantation: Tenth Official Report-1993. J Heart Lung Transplant 1993;12:541–548.
Stevenson, LW, Warner, SL, Steimle, AE, et al. The impending crisis awaiting cardiac transplantation. Modeling a solution based on selection. Circulation 1993;89:450–457.
Ellison, DH. The physiologic basis of diuretic synergism: Its role in treating diuretic resistance. Ann Intern Med 1991;114:97–105.
Coats, AJS. Exercise rehabilitation in chronic heart failure. J Am Coll Cardiol 1993;22:172A-177A.
Kelly, RA, Smith, TW. Digoxin in heart failure: Implications of recent trials. J Am Coll Cardiol 1993;22:107A-112A.
Ferguson, DW, Berg, W, Sanders, JS, Roach, PJ, Kempf, JS, Kiezle, MG. Sympathoinhibitory responses to digitalis glycosides in heart failure patients. Direct evidence from sympathetic neural recordings. Circulation 1989;80:65–77.
Brater, C. The use of diuretics in congestive heart failure. Semin Nephrol 1994;14:479–484.
Packer, M, Medina, N, Yushak, M. Relation between serum sodium concentration and the hemodynamic and clinical responses to converting enzyme inhibition with captopril in severe heart failure. J Am Coll Cardiol 1984;3:1035–1043.
Weber, KT, Villareal, D. Aldosterone and antialdosterone therapy in congestive heart failure. Am J Cardiol 1993;71:3A-11A.
Rimondini, A, Cipolla, CM, Della Bella, P, Grazi, S, Sisillo, E, Susini, G, Guazzi, MD. Hemofiltration as a short-term treatment for refractory congestive heart failure. Am J Med 1987;83:43–48.
Cohn, J, Johnson, G, Ziesche, S, 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.
Stevenson, LW, Perloff, JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989;261:884–888.
Weiland, DS, Konstam, MA, Salem, DN, Martin, TT, Cohen, SR, Zile, MR, Das, D. Contribution of reduced mitral regurgitant volume to vasodilator effect in severe left ventricular failure secondary to coronary artery disease or idiopathic dilated cardiomyopathy. Am J Cardiol 1985;6:171–173.
Packer, M. Is the renin-angiotensin system really unnecessary in patients with severe chronic heart failure: The price we pay for interfering with evolution. J Am Coll Cardiol 1987;316:1429–1435.
Captopril Multicenter Research Group. A placebo-controlled trial of captopril in refractory chronic congestive heart failure. J Am Coll Cardiol 1983;2:755–763.
Consensus Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987;316:1429–1435.
Gibbs, JSR, Keegan, J, Wright, C, Fox, KM, Poole-Wilson, PA. Pulmonary artery pressure changes during exercise and daily activities in chronic heart failure. J Am Coll Cardiol 1990;15:52–61.
vanVliet, AA, Donker, AJM, Nauta, JJP, Verheugt, FWA. Spironolactone in congestive heart failure refractory to high-dose loop diuretic and low-dose angiotensin-converting enzyme inhibitor. Am J Cardiol 1993;71:21A-28A.
Gage, J, Rutman, H, Lucido, D, LeJemtel, TH. Additive effects of dobutamine and amrinone on myocardial contractility and ventricular performance in patients with severe heart failure. Circulation 1986;74:367–373.
Nemanich, JW, Veith, RC, Abrass, IB, Stratton, JR. Effects of metoprolol on rest and exercise cardiac function and plasma catecholamines in chronic congestive heart failure secondary to ischemic or idiopathic cardiomyopathy. Am J Cardiol 1990;66:843–848.
Waagstein, F, Bristow, MR, Swedberg, K, et al. Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Lancet 1993;342:1441–1446.
Waagstein, F, Caidahl, K, Wallentin, I, Bergh, CH, Hjalmarson, A. Long-term betablockade in dilated cardiomyopathy. Effects of short and long-term metoprolol treatment followed by withdrawal and readministration of metoprolol. Circulation 1989;80:551–563.
Packer, M. Lack of relation between ventricular arrhythmias and sudden death in patients with chronic heart failure. Circulation 1992;85:50–56.
Luu, M, Stevenson, WG, Stevenson, LW, Baron, K, Walden, J. Diverse mechanisms of unexpected cardiac arrest in advanced heart failure. Circulation 1989;80:1675–1680.
Winkle, RA, Mead, RH, Ruder, MA, et al. Long-term outcome with the automatic implantable cardioverter-defibrillator. J Am Coll Cardiol 1989;13:1353–1361.
Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation. I. Clinical features of patients at risk. Ann Intern Med 1992;116:1–5.
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Binetti, G., Senni, M., Colombo, F. et al. Medical treatment of eng-stage heart failure. Cardiovasc Drug Ther 10 (Suppl 2), 617–622 (1996). https://doi.org/10.1007/BF00052508
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DOI: https://doi.org/10.1007/BF00052508