W. H. Wilson Tang, MD

ABSTRACT: Angiotensin-converting enzyme inhibitors and ß-blockers are the cornerstone of heart failure medical therapy; unless contraindicated, start these agents as soon as possible after volume status has been optimized. Aldosterone receptor antagonists, angiotensin-receptor blockers, and a fixed-dose combination of hydralazine and isosorbide dinitrate (the last recommended especially for African Americans) can be used as add-on therapy. Prophylactic implantable cardioverter defibrillators reduce long-term mortality in symptomatic patients with a left ventricular ejection fraction (LVEF) of 35% or less. Cardiac resynchronization therapy improves symptoms and ventricular remodeling in some patients; indications include wide (more than 20 milliseconds) QRS complex on ECG, impaired LVEF (35% or less), and advanced heart failure symptoms (NYHA classes III and IV) despite optimal drug therapy. Measurement of natriuretic peptides and impedance cardiography both show promise for monitoring patients with heart failure and for guiding therapy, but definitive data to justify their routine use are still lacking.

Heart failure is prevalent in both primary care and cardiology practices. It develops in about 1 in 5 persons during their lifetime and in about 1 in 8 of those who have not sustained a myocardial infarction (MI). Heart failure is also the leading cause of hospitalization in the elderly.

The past several years have witnessedimportant advances in the evaluationand management of chronic heart failure(HF). Drugs such as β-blockersand spironolactone have been shownto reduce morbidity and mortality, andstrategies that employ new devices,such as pacing and defibrillator therapy,are evolving. This has promptedthe American College of Cardiology(ACC)/American Heart Association(AHA) to update guidelines first publishedin 1995.1 The guidelines highlightthe importance of early and accuraterecognition of the clinical syndromeof chronic HF and offer anoutline for evidence-based therapeuticdecision making.