Which drug for what patient with heart failure, and when?

Congestive heart failure is emerging as an important public health problem because of its frequency and high mortality. Over the past decade, a number of clinical trials have been launched in a systematic attempt to determine an optimal therapeutic strategy for the treatment of heart failure. There appears to be a trend to begin treatment with both a diuretic and a vasodilator regimen in patients with symptomatic left ventricular dysfunction. Converting enzyme inhibitors have been shown to clearly benefit patients with class IV heart failure. The role of digitalis, other inotropic agents, beta-blockers, partial beta-agonists and antiarrhythmic agents is still evolving, but several clinical trials of these agents have been recently launched or are in the planning stages. Patients with symptomless left ventricular dysfunction are at risk to develop heart failure. One attractive hypothesis being tested is that preventive therapy with converting enzyme inhibitors may prevent progressive cardiac dilatation and thereby improve survival in this important reservoir of patients. Until the results of these numerous clinical trials are published, physicians should reserve judgement regarding the undefined efficacy of various investigational agents used in the treatment of heart failure and use their experience and judgement when planning a therapeutic strategy for their individual patients.