Prevention and management of chronic heart failure in patients at risk

The prevalence and incidence of chronic heart failure (HF) have now reached epidemic proportions. However, the issue of the prevention of HF has been raised only recently. New US guidelines have introduced a new classification system that includes 4 categories: patients at risk, patients with asymptomatic left ventricular dysfunction, patients with symptomatic HF, and those with refractory HF. Because coronary artery disease is the major cause of HF, its risk factors are also those of HF. Hypertension favors the development of HF through accelerated atherosclerosis and increased left ventricular wall stress and hypertrophy. Left ventricular hypertrophy is also a powerful risk factor for HF, independent of blood pressure. Angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and diuretics are the antihypertensive agents that have been associated with favorable effects in patients with overt HF. Therefore, they may be preferred in the prevention of this syndrome. Diabetes is the most frequent noncardiac comorbidity of HF and is independently associated with an increased risk. Normalization of glycemic and glycosylated hemoglobin levels is a desirable goal of treatment. However, no direct evidence exists in the prevention of HF. A greater control of the other risk factors (eg, hypertension, hyperlipidemia) is, on the other hand, particularly important. Beta-blockers and ACE inhibitors have both been shown to have favorable effects across all spectrums of severity of HF. The ACE inhibitor ramipril has also been shown to prevent the development of HF in patients at risk without left ventricular dysfunction. The role of antiplatelet agents, warfarin, and statins is clear in the prevention of the coronary artery disease. However, it has not been adequately assessed in patients with HF and awaits the results of ongoing trials.