Unanswered questions in the treatment of heart failure

Chronic heart failure (CHF) is a large medical problem, but in recent years significant progress has been made in its treatment. Angiotensin converting enzyme (ACE) inhibitors and beta-blockers are now the cornerstones in the treatment of CHF, usually in combination with diuretics digoxin. Many other drugs have been developed, but apart from angiotensin II receptor blockers, and possibly aldosterone receptor antagonists, these drugs have not gained a place. The place of device therapy has increased in recent years. Indications for the implantable cardioverter-defibrillator (ICD) are expanding, and new biventricular pacing techniques (cardiac resynchronization therapy [CRT]) are gaining a place. The recent COMPANION study has shown that the combination of CRT and ICD may be the most optimal treatment strategy. Given these rapidly expanding treatment options in CHF, new questions are now emerging. The order in which the various agents are administered is under debate, and it has been suggested that beta-blockers and not ACE inhibitors should be first-line drugs. Also, patient-tailored treatment and pharmacogenomics appear attractive, as is treatment guided by plasma (neurohormonal) parameters. Use of devices (ICD and CRT) is now so common and effective that the indication for implantating them is rapidly moving from advanced to early CHF, but wide application of these devices is expensive. In conclusion, treatment options are still expanding for patients with CHF, which generate new questions, and these must be addressed in future studies. (C) 2003 The European Society of Cardiology. Published by Elsevier Science Ltd. AR rights reserved.