Pharmacological management of chronic heart failure: old drugs, new drugs and new indications

Abstract

British Journal of Hospital Medicine, February 2013, Vol 74, No 2 Heart failure affects 1–2% of the population in the developed world and remains an important cause of hospitalization. After stabilizing patients through the acute phase of their illness, their outcome in terms of mortality, morbidity and further hospitalization can be altered by treatment with appropriate disease-modifying drugs. The hospital doctor plays a crucial role in restarting medications that were stopped during admission, titrating appropriate doses and initiating drugs with long-term benefits. This article gives an overview of the current drug options and the evidence to support their use in practice (Figure 1). The pharmacological therapy discussed focuses on evidence derived in patients with heart failure with impaired systolic function. Old drugs The neurohumoral axis: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers The pathogenesis of heart failure is driven by two neurohumoral systems: the renin– angiotensin–aldosterone system and the sympathetic nervous system. A decrease in cardiac output stimulates activation of these two systems in an attempt to compensate for cardiac dysfunction via vasoconstriction and augmenting cardiac output using the Frank–Starling mechanism. However, left unchecked, the increase pre-load and after-load causes worsening of cardiac function through adverse remodelling of the myocardium and vasculature. Current treatments counteract these adverse remodelling processes. Pharmacological management of chronic heart failure: old drugs, new drugs and new indications