[Symptomatic treatment of chronic cardiac insufficiency]

Given the absence of curative and preventive treatment of cardiac failure, symptomatic therapy is very important. In severe "non-ambulatory" cardiac failure, symptoms depend on the patient's resting hemodynamic status. This can be improved by diuretics, digitalis and vasodilators. A combination of these three drug groups is often required. However, the respective value of each group is unknown. Their use is limited by their specific undesirable secondary effects which are particularly common and severe at this advanced stage. Their effects on survival are unknown with the exception of angiotension converting enzyme inhibitors which have been shown to be beneficial. At the ambulatory stage symptoms occur on effort. In order to improve exercise capacity, the treatment chosen should increase the patient's reserve of cardiac output, limit the increase in pulmonary pressures, respect systemic arterial pressure, decrease venous pressure, dilate the muscular arterioles and improve oxygen extraction by skeletal muscle during physical exercise. Diuretics and angiotensin converting enzyme inhibitors can fulfill these objectives. The effects of the other vasodilators are more variable, due to a vasodilatation which is often inappropriate and to tachyphylaxis related to reflex activation of neuro-hormonal mechanisms. Digitalis and some vasodilator inotropic agents can improve symptoms and effort capacity. However, doubts over possible deleterious effects on mortality have to be cleared by large scale, controlled therapeutic trials. Symptoms of cardiac failure at the ambulatory stage and the effects of treatment on these symptoms should logically be evaluated by appropriate ergometric exercise stress testing, with measurement of the patient's maximum oxygen consumption whenever possible.(ABSTRACT TRUNCATED AT 250 WORDS)