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Recognition and management of asymptomatic patients with left ventricular dysfunction
1Department of Medicine/Division of Cardiology, University of Texas Health Science Center, San Antonio 78284-7872.
Insights
Newer congestive heart failure therapies, including angiotensin-converting enzyme (ACE) inhibitors, improve survival in symptomatic patients. However, their benefit for asymptomatic patients with reduced left ventricular (LV) function remains unclear.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Congestive heart failure (CHF) therapy has advanced with vasodilator drugs.
- Vasodilator therapy, combined with digitalis and diuretics, improves left ventricular (LV) ejection fraction, functional capacity, and quality of life.
Purpose of the Study:
- To evaluate therapeutic approaches for asymptomatic patients with significantly depressed LV function.
- To consider the use of cardiac glycosides and angiotensin-converting enzyme (ACE) inhibitors in this patient group.
Main Methods:
- Review of studies published since 1988 on vasodilator and ACE inhibitor therapy.
- Consideration of objective measurements of ventricular function for prognosis in asymptomatic patients.
Main Results:
- ACE inhibitors improve survival in symptomatic CHF patients.
- Data are lacking to confirm improved survival with interventions in asymptomatic patients with depressed LV function.
Conclusions:
- Prognosis for asymptomatic patients with depressed LV function should rely on objective measurements, not NYHA class.
- Therapeutic decisions for asymptomatic patients must be individualized, weighing potential benefits against current evidence.
Abstract:
In recent years there have been encouraging developments in the therapy for congestive heart failure. Vasodilator therapy, as an adjunct to digitalis and diuretics, has made a major impact. Vasodilator therapy results in improved left ventricular (LV) ejection fraction, improved functional capacity, and enhanced quality of life. When an angiotensin-converting enzyme (ACE) inhibitor is used, several studies published since 1988 show that these improvements are accompanied by improved survival. Yet many questions remain. Principal among these is how to approach the patient who has significantly depressed LV function, but is asymptomatic or has only minimal symptoms. In these patients the prognosis cannot be based on New York Heart Association (NYHA) functional class, but must reflect objective measurements of ventricular function. Any intervention should be specifically designed to improve survival, since functional capacity and quality of life are apparently unimpaired. On the other hand, there are no data at present to suggest that intervention in these patients will improve survival. This article considers the evaluation of such asymptomatic patients and potential therapeutic approaches. These are the use of cardiac glycosides, the use of ACE inhibitors, or their combination. Circumstantial evidence supporting their use in this select patient population is considered. It is stressed that any decision to intervene therapeutically in the asymptomatic patient must be made by the physician on an individual basis.