Therapy of chronic heart failure (CHF) is designed to: (i) improve the quality of life by reducing symptoms; (ii) lengthen survival; and (iii) slow the progression of cardiac deterioration. CHF typically has an underlying cause such as ischaemic heart disease, and may be exacerbated by specific precipitating factors such as infection or arrhythmias, as well as by myocardial abnormalities which develop as CHF progresses (e.g. valvular dysfunction). As well as the symptoms of CHF per se, both underlying and precipitating factors should, if possible, be treated. Restricting activity and reducing dietary sodium help to lessen cardiac workload and fluid retention.

The sympathetic and renin–angiotensin–aldosterone (RAA) systems activated in response to reduced pump function initially help to maintain cardiac output, but also drive the progression of cardiac deterioration (Figure 47; see also Chapter 46). Therapy mainly involves inhibiting these systems, and is initiated with angiotensin-converting enzyme inhibitors (ACEI) or β-blockers, which slow CHF progression, lengthen survival time and improve haemodynamic parameters. Angiotensin receptor blockers (ARBs) are used as an alternative in patients who cannot tolerate ACEI. If symptoms are not adequately controlled with one of these three types of drugs, one of the other classes is then also prescribed. Typically, a drug targeting the RAA system is combined with a β-blocker, although the ACEI–ARB combination can be used in β-blocker intolerant patients. Combining all three classes has been shown not to be beneficial and potentially increases side effects, so is not recommended. A diuretic can also be used to control fluid accumulation and digoxin may be used to support cardiac function and reduce symptoms. In severe or refractory CHF, or when existing therapy fails to control symptoms adequately, an aldosterone antagonist such as spironolactone or eplerenone is recommended. Positive inotropes such as dobutamine, dopamine or milrinone may be used temporarily if decompensation (an acute worsening of heart failure) occurs, as can intra-aortic balloon counterpulsation (see Chapter 45).

Device therapy is playing an increasingly important role in treating chronic heart failure. Implantable cardiac defibrillators are used in many patients with moderate to severe CHF, as ∼50% of patients will have sudden cardiac death, which is mainly caused by ventricular fibrillation (see Chapter 50). Cardiac resynchronization therapy, which involves implantation of a pacemaker that stimulates both ventricles to contract simultaneously, can also be used in patients with moderate to severe CHF who show evidence of asynchronous ventricular contraction.

A ventricular assist device (a pump that takes over part or all of the heart’s pumping action) can be used as a bridge for patients awaiting cardiac transplant, or as a destination device to lengthen survival if transplant is not possible.

ACEI and Other Vasodilators

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