Treating Patients with Severe Heart Failure

Abstract

The roles of the renin-angiotensin system and the sympathetic nervous system in the pathogenesis and progression of heart failure are well established. Angiotensin-converting enzyme (ACE) inhibitors and ss-adrenergic-receptor antagonists have been shown to slow down and, in many cases, reverse the process of cardiac remodeling, thus leading to improved cardiac function and clinical outcomes in patients with heart failure. Standard treatment for heart failure consists of a diuretic, an ACE inhibitor (or angiotensin-receptor blocker if the ACE inhibitor is not well tolerated), a ss-blocker, and low-dose digoxin (if needed). Numerous clinical trials have demonstrated reductions in morbidity and mortality with this combination of medications. However, the majority of patients included in these clinical trials had New York Heart Association (NYHA) functional class II or III heart failure. Because few patients with NYHA class IV heart failure have been evaluated in clinical trials, the treatment approach in this patient population is less well defined. The purpose of this article is to review the results of clinical trials with ss-blockers that included patients with severe heart failure.