[Cardiac and extracardiac parameters as principles in differential therapeutic considerations for decreasing pre- and...

A differential therapy of congestive heart failure requires the identification of the different stages of myocardial damage consequent to the underlying heart disease and the individual adaptive response to it. Because of their different load dependence, it is important to recognize the independent contribution of systolic and diastolic dysfunction in congestive heart failure. The vertical displacement of the diastolic pressure-volume loop is associated with a reduced therapeutic range. Reducing preload may limit the degree of diastolic filling necessary to fill a noncompliant heart and limit active myocardial stretch. The final outcome of any disorder is either to comprise cardiac filling, emptying, or both. When the end-stage is reached, only modification of excessive neurohormonal responses to heart failure remains. Efforts are necessary to avoid substances able to support the maladaptation. The rational use of vasodilator therapy in congestive heart failure is based on the concept that peripheral circulatory mechanisms overshoot, and may thereby act to exacerbate the heart failure. As important as it is to modify late neurohormonal responses, it is even more important to intervene at an earlier stage to reduce the degree of irreversible myocardial damage. Further studies have to prove the potential benefits of ACE-inhibitors in patients with mild heart failure in order to prevent or delay the progress of the disease.