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Vol. 23, No. 3, March 2000 (Supplement III)

Best Practices for Optimally Treated Advanced Heart Failure

MICHAEL L. BRISTOW, M.D., PH.D., Guest Editor


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CONTENTS

Best Practices for Optimal Treatment of Advanced Heart Failure

M. R. Bristow, M.D., Ph.D.

Introduction

Heart failure is a common disease and a major cause of morbidity and mortality. Since patients with advanced heart failure (AHF) are among the most critically ill cardiac patients and account for a large portion of health care costs, it is important to define the AHF population and identify appropriate treatment strategies for these patients. This supplement's articles are based on a symposium held last March at the American College of Cardiology meeting. The articles focus on AHF from several different perspectives. The first article will address the effect of hospitalization and its economic impact on the cost of heart failure (HF). The subsequent paper deals with current approaches that optimize treatment and management of AHF. In the final article, the synergies of beta-blocking agents and phosphodiesterase inhibitors are highlighted to underscore how this combination might help to reverse/slow the heart failure disease process in AHF patients. It is hoped that this focus of attention on AHF will stimulate further investigation designed to deal effectively with this important health care problem. —Michael R. Bristow, M.D., Ph.D., Chairperson

Maximizing Management of Patients with Decompensated Heart Failure [Full text HTML]

E. Loh, M.D.

Decompensated congestive heart failure is a complex clinical disorder that requires a multifaceted treatment approach. This article will review the role of pulmonary artery catheterization, the use of inotropic agents, and the role of left ventricular assist devices and heart transplantation as therapeutic options for patients who present with decompensated heart failure.

The Economic Burden of Heart Failure [Full text HTML]

J. B. O'Connell, M.D.

Heart failure, a major cause of morbidity and mortality among the elderly, is a serious public health problem. As the population ages and the prevalence of heart failure increases, expenditures related to the care of these patients will climb dramatically. As a result, the health care industry must develop strategies to contain this staggering economic burden. Strategies may include adopting approaches for preventing heart failure and implementing new treatment modalities with proven efficacy into large-scale clinical practice. Successful implementation of these strategies will require intensive physician and patient education and development of innovative approaches to fund support services.

Inotropes in the Beta-Blocker Era [Full text HTML]

B. D. Lowes, M.D., M.A. Simon, M.D., T. O. Tsvetkova, M.D., Michael R. Bristow, M.D., Ph.D.

Beta-adrenergic blocking agents are now standard treatment for subjects with mild to moderate heart failure. However, subjects who decompensate on beta blockade often need treatment with a positive inotropic agent. Phosphodiesterase inhibitors (PDEIs) such as milrinone or enoximone retain their full hemodynamic effects in the face of complete beta blockade, because (1) the site of PDEI action is beyond the beta-adrenergic receptor, and (2) beta blockade reverses receptor pathway desensitization changes, which attenuate the PDEI hemodynamic response. Moreover, when PDEIs and beta-blocking agents are coadministered long term in chronic heart failure, their respective efficacies are additive and their adverse effects are subtractive. However, large placebo-controlled studies with PDEIs and beta blockers are needed to establish the efficacy and safety of this promising new treatment approach.


This supplement is sponsored by an unrestricted educational grant from Sanofi-Synthelabo, Inc.

The editorial content of supplements is reviewed by the guest editor and approved by C. Richard Conti, M.D., Editor-in-Chief of the Journal. The findings presented in this supplement are those of the contributors and not necessarily those of the sponsor, the publisher, or the editors of Clinical Cardiology.

Clinical judgment must guide each physician in weighing the benefits of treatment against the risk of toxicity. References made in the articles may indicate uses of drugs at dosages, for periods of time, and in combinations not included in the current prescribing information.