Heart Failure: Update on Therapeutic Options

Heart failure statistics are daunting: 550,000 new cases each year, a 1-year mortality rate of nearly 20%, and annual direct and indirect costs that total $24.3 billion.1 The diverse etiology of heart failure and the complex, progressive course of the disease can make treatment decisions daunting as well. Here I discuss current recommendations for heart failure management, as well as the clinical implications of the results of recent studies. RISK FACTORS Among the 5143 participants in the original Framingham Heart and Offspring studies, the most common risk factor for heart failure was hypertension. Of those study participants in whom heart failure developed, 91% were hypertensive.2 Among hypertensive men and women in these studies, myocardial infarction (MI), diabetes, left ventricular hypertrophy, and valvular heart disease were cofactors that were associated with an increased risk of heart failure. MI was a particularly common cofactor in this group; 52% of the men with heart failure and 34% of the women had a history of MI.2PATHOPHYSIOLOGY The pathophysiology of heart failure involves both hemodynamic and neurohormonal abnormalities, although the interactions between them are incompletely understood. Survival benefits that result from drug-induced decreases in neurohormonal activity underscore the role of increased neurohormonal activity in chronic heart failure. Impaired left ventricular function activates neuroendocrine compensatory mechanisms, both vasoconstrictive and vasodilative. The primary vasoconstrictive systems are the sympathetic nervous system and the reninangiotensin system. Increased plasma levels of norepinephrine, which reflect sympathetic nervous system activity, have been correlated directly with disease severity and mortality in heart failure.3 Activation of the renin-angiotensin system increases systemic vascular resistance and has also been correlated with disease progression. DIAGNOSIS The history and physical findings often point to heart failure. Common presenting symptoms in patients with left ventricular dysfunction are: