IntroductionItalo de Luca, MD

The results of large-scale, controlled clinical trialsconducted in the past 10 years have contributed

significantly to the modification of the treatment ofpatients with chronic heart disease, leading to relief ofsymptoms and an increase in life expectancy. How-ever, therapeutic progress has not been able to stop thecontinuous increase in the morbidity or mortalitycaused by heart failure, which remains a major healthproblem for Western countries. The reasons for thisare to be found in the progressive aging of the popu-lation, the inadequacy of health care service programsand structures, and the underuse of proven and effec-tive therapies. Rapid updating of the medical profes-sion in regard to these problems is imperative.

This supplement to The American Journal of Car-diology is intended to provide the practicing physicianwith the latest information on the prevention andmanagement of chronic heart failure. This informationwas gathered from the 2002 VII International Con-gress of Cardiologia 2000, held in Ostuni, Italy, whichwas organized with the help of Dr. Robert O. Bonowand Dr. Mihai Gheorghiade of Northwestern Univer-sity in Chicago.

Dr. Maria Frigerio and colleagues consider theusefulness of a screening program aimed at usingsuitable treatment to reduce the morbidity and mor-tality of patients. This approach currently includesangiotensin-converting enzyme inhibitors and�-blockers together with antiplatelets and statins if thepatient has coronary artery disease. Natriuretic pep-tides—brain natriuretic peptide (BNP) and the N-terminal proBNP—are proposed in many studies as asensitive screening tool to exclude the syndrome or toidentify, among subjects at high risk, those patientswho need to undergo echocardiography, which is nowa “gold standard” for evaluation of left ventriculardysfunction. However, because this strategy is ratherexpensive, it is necessary to evaluate whether it iscost-effective.

Clinical research and epidemiologic studies have

shown that heart failure represents a sequence ofevents that start with patients at high risk (stage A)and that evolve toward asymptomatic left ventricularsystolic dysfunction (stage B), symptomatic heart fail-ure (stage C), and advanced heart failure (stage D).These 4 stages were identified in the revised guide-lines published by the American College of Cardiol-ogy/American Heart Association (ACC/AHA) in2001. Dr. Livio Dei Cas and colleagues discuss thenew classification, which emphasizes that disease pro-gression can be slowed down or stopped with thera-pies, even before the signs and symptoms of leftventricular dysfunction appear. The efforts of cardiol-ogists must concentrate primarily on the identificationof high-risk patients and on the treatment of the initialstages of the disease.

The work of Dr. Liviu Klein and associates is anupdated review of current pharmacologic therapies forpatients with symptomatic systolic heart failure. Dr.Klein’s team considers that although acute symptomsare related to hemodynamic anomalies, the progres-sion of heart failure, which includes death, is related toneurohormonal activation, as well as to vascular andventricular remodeling. For this reason, in addition toinvestigational therapies (eg, vasopeptidase inhibitors,cytokine antagonists, endothelin antagonists), Klein et

From the Department of Cardiology, Azienda Policlinico Hospital,Bari, Italy.

Address for reprints: Italo de Luca, MD, Department of Cardiol-ogy, Azienda Policlinico Hospital, 70124 Bari, Italy. E-mail:i_deluca@libero.it. Italo de Luca, MD

1F©2003 by Excerpta Medica, Inc. 0002-9149/03/$ – see front matterAll rights reserved. doi:10.1016/S0002-9149(02)03334-9

al distinguish the life-saving therapies that have neu-rohormonal effects, which have been demonstrated todecrease or stop the progression of heart failure (an-giotensin-converting enzyme inhibitors, �-adrenergicreceptor blockers, aldosterone antagonists), from (1)palliative therapies (digoxin, diuretics), (2) therapiesassociated with a possible increase in survival (angio-tensin II receptor blockers, combination hydralazine-isosorbide), and (3) therapies considered detrimental(calcium antagonists, positive inotropic agents, sys-temic vasodilators, antiarrhythmic agents).

The article underlines 4 practical considerations:(1) coronary artery disease has replaced hypertensionand valvular heart disease as the most common etiol-ogy for heart failure; (2) there is an increased preva-lence of patients with heart failure and preservedsystolic function; (3) because of therapeutic interven-tion, most patients die, not because of systemic andpulmonary congestion, but of sudden cardiac death,before developing significant worsening of the dis-ease; and (4) a holistic approach must be taken in thetreatment of each patient because various conditions,such as coronary artery disease, hypertension, diabetesmellitus, atrial fibrillation, and systolic and diastolicdysfunction, may coexist in the same patient. It isclear that each situation requires ad hoc individualizedmanagement.

Dr. Paolo Colonna and colleagues, and Dr.Michele D’Alto and co-workers report certain usefulinterventions to accompany pharmacologic treatment.Clearly, there is the need to improve the nonpharma-cologic approach aimed essentially at suggesting mod-ifications to the patient’s diet and lifestyle and edu-cating both the patient and family in a way that en-courages compliance with the therapeutic regimen andthe lifestyle changes. Indeed, several studies havedescribed appropriate allocation of resources and amultidisciplinary program. Collaboration of the spe-cialist with the family doctor and the nursing staff, aswell as with the dietitian, psychologist, and physio-therapist, leads to clear benefits in the quality and thequantity of life of the patients and in a reduction inhealth care costs.

Although there is convincing evidence that syn-chronous biventricular pacing may be beneficial innonpharmacologic treatment of advanced heart fail-ure, Dr. Gerardo Ansalone and associates suggest thattissue Doppler imaging improves the concordance be-tween the delayed site and the pacing site and mayreduce the percentage of nonresponders to biventricu-lar treatment.

Biventricular pacing may not prolong life; it maysimply convert the mode of death from progressiveventricular failure to sudden cardiac death, especiallyin patients with advanced heart failure who may needmore aggressive approaches for arrhythmia control.Combined electrical therapies that incorporate multi-site or single-site pacing and ICD therapy have beenproposed as a rational means for hemodynamic ben-efits and sudden cardiac death prevention.

Dr. Erica D. Engelstein reports results of studiesconducted in the electrical therapy of arrhythmias in

patients with heart failure. In addition, she outlinesquestions that will have to be answered: (1) Doesimplantable cardioverter defibrillator (ICD) therapyreduce mortality in patients with nonischemic cardio-myopathy? (2) Should patients with recent (�4weeks) myocardial infarction and reduced left ventric-ular function receive an ICD? (3) What is the optimalsite for ventricular pacing? (4) Which patients mightbe candidates for ventricular tachycardia ablation asthe sole therapy? (5) Can electrical therapy of atrialfibrillation improve morbidity and mortality comparedwith a rate-control approach? (6) Will cardiac resyn-chronization therapy improve survival in patients withheart failure?

Dr. Carlo Pappone and colleagues report on theMilan experience with the biventricular pacing–defi-brillation backup combination for advanced heart fail-ure and for primary prevention of sudden cardiacdeath. Despite the high costs of such an approach, thepreliminary data are encouraging enough to supportthe need for further large-scale investigations.

Contributions to this supplement were made by car-diologists and surgeons at the meeting who spoke aboutnew surgical therapies and strategies for treating heartfailure. Dr. Ottavio Alfieri and associates discuss currentsurgical procedures designed to arrest or reverse theventricular remodeling process in patients with heartfailure. The article describes the results, advantages, andlimits to the main surgical procedures for surgical resto-ration of the left ventricular size and shape, performed asalternatives to heart transplantation. These proceduresare as follows: (1) partial left ventriculectomy, originallydescribed by Batista et al1; (2) endoventricular patchplasty repair, as proposed by Dor2 in patients with anakinetic scar or dyskinetic aneurysm; (3) correction ofmitral regurgitation, as proposed by Bolling et al,3 and,when necessary, the addition of a central edge-to-edgestitch creating a double orifice mitral valve, as proposedby Alfieri et al4; and (4) “extreme” coronary arterybypass graft surgery in patients with severe left ventric-ular dysfunction and documented ischemia. Cardiomyo-plasty and, in particular, the passive containment of theheart using a special fabric net (Acorn Cardiac SupportDevice; Acorn Cardiovascular Inc., St. Paul, MN) shouldalso be considered as a useful adjunct to other surgicalprocedures. The investigators believe that, in the future,the role of surgery in the treatment of heart failure will bestrongly modified by the advent of gene therapy, celltherapy, and engineered artificial myocardial tissue.

Dr. Ettore Vitali and colleagues report on 610 pa-tients who underwent heart transplantation, which re-mains the most effective therapy for end-stage heartdisease, between 1985 and 2001. Increasing use of theventricular assist device has been suggested for patientswith end-stage heart disease as a bridge to heart trans-plantation. The implantation of a permanent device as analternative to heart transplant seems very attractive be-cause of the shortage of donors and the unsuitability ofsome patients for transplantation. The future in this fieldwill depend on the results of ongoing studies on bioma-terials, gene therapy, and new pharmacologic agents.

2F THE AMERICAN JOURNAL OF CARDIOLOGY� VOL. 91 (9A) MAY 8, 2003

The article concludes that there is reason to believe thatthese obstacles will eventually be overcome.

In conclusion, the progressive worldwide decreasein heart transplantation and the dramatic increase inthe number of patients with heart failure mean thatmore articulated multidisciplinary outpatient pro-grams and more efficacious medical and surgical treat-ments must be developed.

1. Batista RJV, Santos JLV, Takeshita N, Bocchino L, Lima PN, Cunha MA.Partial left ventriculectomy to improve left ventricular function in end-stage heartdisease. J Card Surg 1996;11:96–97.2. Dor V. The endoventricular circular patch plasty (“Dor procedure”) in isch-emic akinetic dilated ventricles. Heart Fail Rev 2001;6:187–193.3. Bolling SF, Deeb GM, Brunsting LA, Bach DS. Early outcome of mitral valvereconstruction in patients with end-stage cardiomyopathy. J Thorac CardiovascSurg 1995;109:676–682.4. Alfieri O, Maisano F, De Bonis M, Stefano PL, Torracca L, Oppizzi M. Thedouble orifice technique in mitral repair. A simple solution for complex problems.J Thorac Cardiovasc Surg 2001;122:467–481.

A SYMPOSIUM: FROM PREVENTION TO MANAGEMENT OF CHRONIC HEART FAILURE 3F