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(Circulation. 2001;103:1611.)
© 2001 American Heart Association, Inc.

Editorial

How Many Medicines Do Patients With Heart Failure Need?

William W. Parmley, MD

From the University of California at San Francisco.

Correspondence to William W. Parmley, MD, Professor of Medicine, UCSF, 1180 Moffitt Hospital, 505 Parnassus Ave, San Francisco, CA 94143-0124. E-mail parmley@medicine.UCSF.edu

Key Words: Editorials • heart failure • remodeling

Over the past 2 decades, a number of controlled clinical trials have been performed that have taught us that polypharmacy for heart failure is necessary to achieve the best reduction in morbidity and mortality. Four drugs are given to patients with moderately severe heart failure: digoxin, a loop diuretic, an ACE inhibitor, and a ß-blocker. Although no mortality trials have been done with diuretics, the clinical experience is that they are both necessary and effective agents for reducing volume overload and decreasing symptoms of dyspnea. Although the Digitalis Investigation Group did not show any reduction in mortality with digoxin, there was a reduction in the hospitalization rate.¹ Furthermore, other trials have shown clinical benefit with this drug. Both ACE inhibitors and ß-blockers have a plethora of evidence showing that they reduce mortality and morbidity in patients with heart failure.^{2 3 4 5} In class IV patients, the aldosterone antagonist spironolactone also reduced mortality.⁶ Whether spironolactone is also beneficial in less severe heart failure is not known, but it is increasingly being used in that setting. Some data indicate that ß-blockers may be helpful in patients with class IV heart failure (Carvedilol Prospective Randomized Cumulative Survival [COPERNICUS] Trial; presented at 22nd Congress of European Society of Cardiology, August 2000). Thus, there are now 5 agents that can be considered part of standard therapy for heart failure. Despite this effective pharmacotherapy, however, patients continue to slide downhill over time and, although physicians reduce mortality with these drugs, the curve is merely shifting to the right.

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