Management of Heart Failure I.

Pharmacologic Treatment

David W. Baker, MD, MPH; Marvin A. Konstam, MD; Michael Bottorff, PharmD; Bertram Pitt, MD

Objective.\p=m-\Thisreview of the pharmacologic treatment of heart failure due to left ventricular systolic dysfunction summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. It provides specific advice to help guide practitioners through clinical decision making.

Data Sources.\p=m-\Datawere obtained from English-language studies and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific treatments. Where data were lacking, we relied on opinions of panel members and peer reviewers. Study Selection.\p=m-\Onlylarge prospective trials were used to estimate treatment efficacy. Smaller trials, case series, and case reports were reviewed for the incidence of adverse effects. Data Extraction and Synthesis.\p=m-\Randomizedclinical trials were reviewed for inclusion and exclusion criteria, patient outcomes, adverse effects, and eight categories of study quality using a defined list of study flaws. Conclusion.\p=m-\Angiotensin-convertingenzyme (ACE) inhibitors should be given to all patients unless specific contraindications exist. Diuretics should be used judiciously early in treatment to prevent excessive diuresis that could prevent titration of ACE inhibitors to target doses. Digoxin has not been shown to affect the natural history of heart failure and should be reserved for patients who remain symptomatic after treatment with ACE inhibitors and diuretics. Isosorbide dinitrate and hydralazine hydrochloride should be tried in patients who cannot tolerate ACE inhibitors or who have refractory symptoms. (JAMA. 1994;272:1361-1366)

From the Health Sciences Program, RAND, Santa Monica, Calif (Dr Baker); the Division of General Internal Medicine, Harbor-UCLA Medical Center, Torrance, Calif (Dr Baker); the Departments of Medicine and Radiology, Tufts University, Boston, Mass (Dr Konstam); New England Medical Center, Boston, Mass (Dr Konstam); College of Pharmacy, University of Cincinnati (Ohio) (Dr Bottorff); and the University of Michigan School of Medicine, Ann Arbor (Dr Pitt). Dr Baker is now with the Division of General Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Ga. The views expressed herein are those of the authors and do not reflect the position of the Agency for Health Care Policy and Research, the US Public Health Service, or the US Department of Health and Human Services. Reprint requests to New England Medical Center, Box 108, 750 Washington St, Boston, MA 02111 (Dr

Konstam).

DURING the last few years there have been several major advances in the phar¬ macologie treatment of patients with heart failure due to left ventricular sys¬ tolic dysfunction. Mortality can now be reduced and functional status im¬ proved.13 However, despite the wide¬ spread publicity for these studies, along with excellent reviews and books on the management of heart failure,4"6 there is a strong impression among heart failure experts that the pharmacologie treat¬ ment of patients with heart failure re¬ mains suboptimal. This deficiency may result from clinicians' relative inexpe-

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rience with newer pharmacologie agents, exaggerated concerns over adverse ef¬ fects, or the lack of unambiguous man¬ agement recommendations. For editorial comment

see

1374.

This review will attempt to provide clear, specific recommendations concern¬ ing the pharmacologie treatment of pa¬

tients with heart failure due to left ven¬ tricular systolic dysfunction (ejection fraction,