Controversies in the Management of Heart Failure [antikvár]

Heart failure is a fascinating cluster of syndromes, full of paradoxes, defles simple definition yet is common and deadly. Heart failure is a problem that has taxed physicians for millennia. Myocardial infarction (MI) and hypertension are both products of the 20th century and even angina has been around for only 200 years. However, compared to its younger, and less deadly, cousins little was known about the epidemiology, natural history and effective treatment of heart failure until about a decade ago. Heart failure was perceived to be the final common pathway of many other diseases and it was assumed, by many, that better treatment of antecedent conditions such as valve disease, hypertension and coronary disease would abolish heart failure. This concept now appears naive. As other cardiovascular conditions have declined the prevalence of heart failure has, paradoxically, increased. This probably reflects, in part, the ageing of the population but may alsó reflect the very improvements in management of MI that were expected to abolish heart failure.1 The clinical science of heart failure alsó suffers from the belief by many physicians that the principles of treatment of hypertension and coronary disease, important antecedents of heart failure, can be extrapolated to its management. This is far from clear. For instance the hypertension expert may consider that reducing blood pressure is the key to improving heart failure, after all angiotensin converting enzyme (ACE) inhibitors are effective. But what about alpha-blockers and most calcium antagonists, effective anti-hypertensive agents that can make heart failure worse. Aspirin may be effective for patients with preserved ventricular function and coronary disease but the current balance of evidence suggests that aspirin is ineffective or harmful when heart failure is present.2 Perhaps alsó, paradoxically, it is because heart failure is an 'old' disease that effective treatment has been delayed. The management of heart failure was, and remains, dominated by preconceived ideas that only now are being challenged. There is little evidence to sup-