[Chronic heart failure: improvement of the prognosis by therapy?]

There are two goals in the management of chronic heart failure: relief of symptoms and prolongation of life. Until recently, pharmacological interventions were tested primarily in order to evaluate their effects on exercise capacity and clinical symptoms. However, two multicenter trials have now provided evidence that treatment of chronic heart failure is able to improve mortality. Indeed, prolongation of life without improving symptoms is not desirable. The two classic keystones of therapy in heart failure, diuretics and digitalis, remain powerful agents to relieve symptoms. However, their impact on survival remains elusive, since no controlled studies are available which address this question with adequate sample size. Vasodilators such as the combination of hydralazine and isosorbide dinitrate and ACE-inhibitors, however, have been shown to improve survival in patients with moderate to severe chronic heart failure. In contrast, prazosin failed to be effective in this respect. More sophisticated questions emerge, in particular, do ACE-inhibitors or vasodilators, effectively interfere with the progression of the disease? May early treatment be preventive and retard the course of heart failure? Several large scale multicenter trials are now under way to address these issues.