HEART FAILURE
Clinical Overview

Pharmacotherapy

 

Pharmacological Management of
Patients with Left Ventricular Systolic Dysfunction

This algorithm illustrates the pharmacologic management of heart failure due to left-ventricular systolic dysfunction as recommended by the AHCPR guideline panel. Medications are selected based on the heart failure symptoms of dyspnea on exertion (DOE) and clinical volume overload.¹Angiotensin-converting enzyme inhibitors are considered first-line therapy for patients with mild DOE and no clinical symptoms of volume overload. For those with moderate DOE, with or without volume overload, diuretics are recommended, followed by an ACE inhibitor, and for severe DOE, digoxin should also be added.

If symptoms do not resolve with the addition of digoxin therapy, some additional measures are:

• aggressive diuretic therapy for persistent volume overload
• hydralazine and/or nitrates for persistent dyspnea
• direct vasodilator or alpha-blocker for persistent hypertension
• nitrates and aspirin or perhaps the very cautious use of beta-blockers or calcium channel blockers for concomitant angina.

The pharmacologic management of heart failure due to left ventricular diastolic dysfunction is not discussed in this Pharmacotherapy section. The treatment of diastolic heart failure is different from the treatment of systolic heart failure. Unfortunately, there are no large scale clinical trials examining drug therapy for diastolic dysfunction. Drugs that slow the heart rate are the preferred treatment for this patient population. A few small trials have shown that calcium channel blockers, such as verapamil, are effective in the treatment of patients with diastolic dysfunction by decreasing symptoms and improving exercise tolerance. Other trials have shown beta-blockers to be beneficial in diastolic dysfunction. The benefit of ACE inhibitors has not yet been conclusively demonstrated. However, digoxin may actually promote diastolic dysfunction.^{2 ,3}

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