Integrating traditional and emerging treatment options in heart failure.

PURPOSE: This paper reviews traditional approaches for the management of heart failure, as well as the emerging approach of using an aldosterone inhibitor.

SUMMARY: In addition to prevention, the goals of heart failure therapy are to relieve symptoms, improve quality of life, slow progression of heart failure through both pharmacologic and nonpharmacologic therapies, minimize or prevent acute exacerbations, reduce hospitalizations, improve survival, favorably influence neurohormones, and reduce costs. Symptoms are alleviated with diuretics and digoxin; if digoxin is used, the target therapeutic range appears to be 0.4-0.8 ng/mL. Large, well-controlled clinical trials have documented the effectiveness of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking agents in reducing the mortality and morbidity in patients with heart failure ranging from post myocardial infarction left ventricular dysfunction to severe heart failure. Recent large studies have documented the effectiveness of aldosterone receptor antagonists in improving mortality and morbidity in patients with heart failure. There was a 30% reduction in mortality in patients with NYHA class III-IV heart failure when spironolactone compared with placebo was added to a regimen consisting of digoxin, furosemide, and an ACE inhibitor. A later study in which a gamma-blocker was also included in the regimen showed that patients with left ventricular systolic dysfunction with symptoms of mild heart failure following myocardial infarction taking eplerenone had a 15% relative reduction in all-cause mortality and a 21% reduction in sudden cardiac death compared with placebo. The incidence of gynecomastia was 9% and 0.5% for spironolactone and eplerenone, respectively.

CONCLUSION

The data support adding aldosterone receptor antagonists alongside ACE inhibitors and beta-adrenergic blocking agents as ways to reduce mortality and morbidity in the treatment algorithm for heart failure. More research is needed to determine the usefulness of aldosterone receptor antagonists across the entire spectrum of heart failure.