Chronic heart failure: developments and perspectives.

Abstract

OBJECTIVE: To describe the clinical presentation, diagnosis, and contemporary treatment of chronic heart failure (CHF) while emphasizing the important role of the pharmacist. DATA SOURCES: English-language articles from MEDLINE pertinent to CHF. STUDY SELECTION AND DATA EXTRACTION: All relevant publications addressing CHF management were considered, including prospective comparative trials, epidemiological studies, guideline statements, review articles, and editorials. Particular focus occurred on the primary literature published after the release of noted guidelines. The Heart Failure Society of America (HFSA), and the European Society of Cardiology (ESC). DATA SYNTHESIS: Heart failure is a common disorder, especially in the elderly. To determine appropriate pharmacotherapy, one must establish the type of dysfunction (systolic versus diastolic) as well as characterize the patient's disease state according to the New York Heart Association (NYHA) functional classification system and from the American College of Cardiology (ACC)/American Heart Association (AHA), stage of diseases. Although most patients have systolic dysfunction ([ejection fraction] less than 40%), the prevalence of diastolic dysfunction (a normal to elevated ejection fraction) is rising and it accounts for at least one-third of all cases. Six drugs/drug classes are contemporary treatments in systolic heart failure, depending on NYHA functional class: angiotensin-converting-enzyme inhibitors, diuretics, beta-blockers, aldosterone antagonists, angiotensin II receptor-blockers, and digoxin. Clinicians should be aware that studies demonstrate all these drugs/drug classes prolong survival in systolic heart failure, except diuretics and digoxin. Some patients with systolic dysfunction also may be candidates for the combination of hydralazine/isosorbide dinitrate as well as nonpharmacological approaches with biventricular pacemakers and/or implantable cardioverter defibrillators. Treatment of diastolic heart failure is less evidence-based, and speculative treatments focus on control of blood pressure, tachycardia, volume overload, and myocardial ischemia. CONCLUSIONS: CHF treatment remains a therapeutic challenge. Pharmacists have an essential role in the care of these patients by avoiding drugs known to exacerbate the disease, promoting optimal pharmacotherapy, and ensuring compliance with prescribed drugs and dietary modifications.