Long-term therapy of patients with heart failure. Drug therapy: from trial results to clinical practice

Heart failure (HF) represents a major problem in Western countries due to its high prevalence, frequent need for hospitalization and extremely severe prognosis. There have been remarkable advances in long-term drug therapy. During the last decade, the use of vasodilatators, in particular of angiotensin-converting enzyme (ACE)-inhibitors, has been added to the traditional therapy based on diuretics and digitalis. There have been several controlled clinical trials demonstrating the long-term benefits of these drugs for survival. ACE-inhibitors have reduced the risk of mortality in HF, not only by their systemic vasodilatator action but also by their positive effects on ventricular remodelling. In fact, their use has led to a reduction in the incidence of sudden death, and progression of pump dysfunction. A reduction in the incidence of coronary events was also observed. ACE-inhibitors, in combination with diuretics and digitalis, have been rightfully introduced into long-term therapy of HF. At present, other pharmacological options, like flosequinan, some ß-blockers, and some calcium antagonists such as felodipine and amlodipine, hold promise, but further controlled trials are required before they can be introduced into the therapeutic repertoire of HF management.