Treatment of heart failure: an update]

During the last years, the results of several trials on heart failure treatment were published or presented at international meetings. The new perspectives concern drug therapy and non-pharmacological strategies, such as cardioverter-defibrillators, biventricular resynchronization and implantable assist devices. Trials on beta-blockers extended the indication to patients with advanced heart failure, but the choice of the "best" beta-blocker to use remains an unsolved issue. Moreover, the concomitant use of ACE-inhibitors and angiotensin II receptor antagonists is a recent acquisition. However, the Val-HeFT results underscored that the add-on hypothesis of a more complete inhibition obtained with the combination of multiple agents was not confirmed in patients already taking ACE-inhibitors and beta-blockers. Regarding the new neurohormonal modulators (omapatrilat, etanercept, endothelin receptor blockers, arginine-vasopressin antagonists), more data are needed before using them in clinical practice. After the publication of the MADIT-II results, the cardioverter-defibrillator implantation will probably spread in patients with previous myocardial infarction and left ventricular dysfunction to prevent sudden death, but the cost-effectiveness ratio is still to be clarified. In the advanced or end-stage heart failure, when the improvement of quality of life represents the main target of therapy, ventricular resynchronization and implantable assist devices may play a role in clinical settings. Before considering them like a real therapeutic option, final results from ongoing investigations should be awaited.