[Practical difficulties in drug prescription in chronic cardiac insufficiency]

Many practical difficulties are encountered by physicians in the medical treatment of chronic cardiac failure. They are related to the choice of drug guided by therapeutic objectives: vasodilators and angiotensin converting enzyme inhibitors are no longer drugs of secondary intention reserved for chronic cardiac failure, but there is no information as to the place of these drugs in early stages of myocardial dysfunction before the appearance of the clinical signs of cardiac failure. Other difficulties are related to the use of many different drugs, to the many secondary effects, sometimes increased by drug interactions; these difficulties are accentuated by the multiplicity of the etiologies of cardiac failure, by the frequency of associated extracardiac disease and by the risks inherent to abnormal myocardial function. In addition, the prescriber must not forget that the drug is not everything in the treatment of cardiac failure and he must be able to recognise the pathology underlying the cardiac failure which may require specific therapy. Finally, the physician must decide the optimal timing for referring patients with very severe cardiac failure for transplantation.