[Medical treatment of cardiac insufficiency. Advances and controversies]

In the treatment of chronic congestive heart failure (CHF), digitalis has empirically proved to be effective in reducing functional signs and symptoms. However, it is among patients treated with digitalis, diuretics and salt-free diet that mortality is still high. Moreover, the use of digitalis derivatives in CHF with sinus rhythm is controverted due to the frequent toxicity of these drugs and to their allegedly weak positive inotropic activity. Current research in this field therefore is oriented towards non-digitalis cardiotonic drugs capable of increasing intracellular calcium concentrations. In actual fact, a better understanding of physiopathological mechanisms has led to the use of vasodilators, and these in turn have shed additional light on regional blood flows and on the role of the renin-angiotensin-aldosterone system. Added to the digitalis-diuretics therapy, vasodilators not only have beneficial effects on haemodynamic parameters and functional symptoms, but they reduce mortality in patients with CHF: recent studies have demonstrated an increase in survival as compared to conventional treatment. This has revived the problem of whether vasodilators should be prescribed in the early stages of CHF, either alone or combined with the usual drugs.