What is the optimal medical management of ischaemic heart failure?

Abstract

Ischaemic heart disease is probably the most important cause of heart failure. All patients with heart failure may benefit from treatment designed to retard progressive ventricular dysfunction and arrhythmias. Patients with heart failure due to ischaemic heart disease may also, theoretically, benefit from treatments designed to relieve ischaemia and prevent coronary occlusion and from revascularisation. However, there is little evidence to show that effective treatments, such as angiotensin converting enzyme (ACE) inhibitors and beta-blockers, exert different effects in patients with heart failure with or without coronary disease. Moreover, there is no evidence that treatment directed specifically at myocardial ischaemia, whether or not symptomatic, or coronary disease alters outcome in patients with heart failure. Some agents, such as aspirin, designed to reduce the risk of coronary occlusion appear ineffective or harmful in patients with heart failure. There is no evidence, yet, that revascularisation improves prognosis in patients with heart failure, even in patients who are demonstrated to have extensive myocardial hibernation. On current evidence, revascularisation should be reserved for the relief of angina. Large-scale, randomised controlled trials are currently underway investigating the role of specific treatments targeted at coronary syndromes in patients who have heart failure. The CHRISTMAS study is investigating the effects of carvedilol in a large cohort of patients with and without hibernating myocardium. The WATCH study is comparing the efficacy of aspirin, clopidogrel and warfarin. The HEART-UK study is assessing the effect of revascularisation on mortality in patients with heart failure and myocardial hibernation. Smaller scale studies are currently assessing the safety and efficacy of statin therapy in patients with heart failure. Only when the results of these and other studies are known will it be possible to come to firm conclusions about whether patients with heart failure and coronary disease should be treated differently from other patients with heart failure due to left ventricular systolic dysfunction.

Demographics, Treatment Regimens and the Use of Angiotensin-Receptor Blockers in Heart Failure: Findings from the Valsartan Heart Failure Trial

“…It is hoped that the recently announced Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) study, involving 4500 patients, will resolve this issue. 45 As mentioned earlier, older patients tend to have higher rates of HF with preserved systolic function that appears to affect response to some treatments. A study by Dautermann et al 46 looked at the effects of ACE inhibitors in 1720 patients hospitalized for HF, 45% of whom had reduced systolic function (EF < 40%) and 55% of whom had their systolic function preserved (EF > 40%).…”

New Therapeutic Options in Congestive Heart Failure: Part I

“…Clearly, the issue in CHF is whether revascularization might substantially improve LV systolic function in patients with significant areas of hibernation. 20 The definition and best means of detecting hibernation are discussed extensively elsewhere. 19 -21 There are, as yet, few data on the prevalence of important myocardial hibernation in patients with CHF.…”

New Therapeutic Options in Congestive Heart Failure

“…25 A number of small and uncontrolled series have suggested that patients with large areas of viable myocardium may have a low interventional risk and a large potential benefit from revascularization. 25 Consequently, 2 clinical trials are currently planned to address the impact of mechanical revascularization on outcome in such patients.…”

“…25 A number of small and uncontrolled series have suggested that patients with large areas of viable myocardium may have a low interventional risk and a large potential benefit from revascularization. 25 Consequently, 2 clinical trials are currently planned to address the impact of mechanical revascularization on outcome in such patients. One is the Heart Failure Revascularization Trial-United Kingdom (HEART-UK) study, comparing percutaneous or surgical revascularization with optimal medical therapy, which will recruit Ϸ800 patients and have a minimum follow-up of Ϸ5 years and a primary end point of all-cause mortality.…”

“…One is the Heart Failure Revascularization Trial-United Kingdom (HEART-UK) study, comparing percutaneous or surgical revascularization with optimal medical therapy, which will recruit Ϸ800 patients and have a minimum follow-up of Ϸ5 years and a primary end point of all-cause mortality. 25 A planned US trial, Surgical Treatment for IsChemic Heart failure (STICH), intends to address 2 hypotheses, one being the revascularization hypothesis and the other an "LV reconstruction hypothesis." 27 The latter concerns the possibility that surgical remodeling to achieve optimum LV shape and size will also reduce morbidity and mortality in these patients.…”