Selection of Optimal Medical Therapy
Kanu Chatterjee
University of California
San Francisco, CA, USA

A systematic approach for the selection of optimal medical therapy for systolic heart failure is presented. This approach relieves volume overload and congestive symptoms with diuretics. Once the symptoms of congestion are relieved, digitalis therapy is started. Once stable, the therapy of choice is angiotensin converting enzyme (ACE) inhibitors. The addition of beta-blockers are discussed. The use of aldosterone antagonists, amiodarone and other therapies are included.

Clinical presentation of systolic heart failure is often volume overload and congestive symptoms. These symptoms are relieved with diuretics. Diuretics are not recommended for long-term treatment. Dr. Chatterjee detailed a systematic approach for the selection of optimal medical therapy for systolic heart failure.

Dr. Chatterjee recommended using diuretics to relieve volume overload and congestive symptoms. Diuretics are not recommended long-term because they produce adverse effects such as increased levels of norepinephrine, angiotensin and vasopressin; increased renal dysfunction; electrolyte abnormalities and promote ventricular remodeling.

Once the symptoms of congestion are relieved, digitalis therapy is started. Once stable, the therapy of choice is ACE inhibitors. ACE inhibitors prevent ventricular remodeling, improve left and right ventricular function, symptoms, quality of life and decrease the risk of mortality. Dr. Chatterjee recommends starting ACE inhibitors at a low dose, and measuring serum sodium. Patients with low sodium levels can become hypotensive with this drug. If ACE inhibitors are not tolerated, angiotensin receptor blocking agents are used.

After stabilizing a patient on triple therapy (diuretics, digitalis, ACE inhibitors), beta-blockers are added. Beta-blockers improve hemodynamics, left and right ventricular function, quality of life, survival, decrease the progression of heart failure and attenuate ventricular remodeling.

If a patient is volume overloaded and does not respond to digitalis or ACE inhibitors, aldosterone antagonists are used. Aldosterone inhibitors improve hemodynamics by decreasing end diastolic volume, end systolic volume, and attenuating ventricular remodeling. Serum sodium and potassium are monitored when aldosterone inhibitors are used.

Patients who do not tolerate beta-blockers are started on amiodarone. When patients are stabilized on amiodarone, they may be switched to beta-blocker therapy. Patients with severe heart failure who are in cardiogenic shock and present with hypotension, tachycardia and low cardiac output, may benefit from a ventricular assist device.

Other therapies discussed by Dr. Chatterjee are the use of combined non-glycosidic ionotropic and beta-blocker therapy. Dr. Chatterjee suggests using these drugs separately. Dr. Chatterjee does not recommend combining ionotropic agents and direct acting vasodilators. Other treatments to consider are immunomodulators, immunoglobulin therapy; and B-type natriuretic factor; their role in heart failure is unclear.


Reporter: Andrea R. Gwosdow, Ph.D.