[Does closely monitored control and therapy adjustment improve the prognosis in patients with severe heart...

The one year mortality of patients with severe congestive heart failure ranges between 30 and 70%. The effect was investigated of a stepped care program, including weekly monitoring and frequent adjustment of medical treatment, on the prognosis of 18 consecutive outpatients with severe congestive heart failure (NYHA class III and IV, 60 +/- 3.5 years). The diagnosis of congestive heart failure was proven by an invasively measured cardiac index below 2.5 l/min/m2 or by a left ventricular ejection fraction below 30%. Plasma adrenaline and noradrenaline values and plasma renin activity were substantially increased in all patients compared with 20 normals. 11 of the heart failure patients had coronary heart disease, 10 with a large left ventricular aneurysm, 6 patients had congestive cardiomyopathy and one patient had valvular heart disease with aortic insufficiency. In 9 patients ventricular tachycardias were registered, four had recurrent syncopes, and in 7 other patients atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardias were found. Medical treatment in all patients included pre- and afterload reduction by vasodilators. 11 patients received digoxin and 8 antiarrhythmic drugs. After a mean follow-up of 25 +/- 3.3 months, the one-year mortality was 7% and the two year mortality 15%. The favorable prognosis in patients in this special care program shows the favorable effects of individualized therapy, of frequent patient monitoring and the influence of strict compliance on survival and symptoms in patients with chronic congestive heart failure.