Long-term therapy of patients with heart failure. Drug therapy: from trial results to clinical practice.

Heart failure (HF) represents a major problem in Western countries due to its high prevalence, frequent need for hospitalization and extremely severe prognosis. There have been remarkable advances in long-term drug therapy. During the last decade, the use of vasodilatators, in particular of angiotensin-converting enzyme (ACE)-inhibitors, has been added to the traditional therapy based on diuretics and digitalis. There have been several controlled clinical trials demonstrating the long-term benefits of these drugs for survival. ACE-inhibitors have reduced the risk of mortality in HF, not only by their systemic vasodilatator action but also by their positive effects on ventricular remodelling. In fact, their use has led to a reduction in the incidence of sudden death, and progression of pump dysfunction. A reduction in the incidence of coronary events was also observed. ACE-inhibitors, in combination with diuretics and digitalis, have been rightfully introduced into long-term therapy of HF. At present, other pharmacological options, like flosequinan, some beta-blockers, and some calcium antagonists such as felodipine and amlodipine, hold promise, but further controlled trials are required before they can be introduced into the therapeutic repertoire of HF management.

[Ergometric test: prognostic significance in the pre-thrombolytic and thrombolytic period]. / Test ergometrico: significato prognostico nell'era pre-trombolitica e trombolitica.

In the pre-thrombolytic era exercise testing showed the ability to identify a low-risk population with a 1 year event rate < 1% and a moderate-high risk group with an event rate up to 17% within 1 year after acute myocardial infarction. The most significant parameters are the markers of compromised left ventricular contractility. Since the introduction of thrombolytic therapy the negative predictive ability of exercise testing has been questioned, due to the frequent occurrence of residual coronary stenosis with atherosclerotic plaque characterized by marked instability, to the point that the usefulness of exercise testing has been challenged. Nevertheless the available information, albeit sparse, seems to confirm that the negative predictive ability of exercise testing is still adequate (good), and certainly not inferior to that in pre-thrombolytic era.

[Effectiveness of treatment with beta-blocking agents and diuretics in fixed combination, in aged hypertensive patients]. / Efficacia della terapia con beta-bloccanti e diuretici in associazione fissa, in pazienti ipertesi di età avanzata.

The antihypertensive activity and tolerability of oxprenolol 80 mg plus chlorthalidone 10 mg in fixed combination were evaluated in 15 hypertensive patients aged more than 60 years (group 1) and, comparatively, in 11 hypertensive patients aged below 60 years (group 2), all with a lying B.P. value greater than 160/100 mmHg at the end of a two weeks placebo wash-out. Lying and standing systolic and diastolic B.P. decreased (P less than 0.001) (lying position: group 1, from 181.0/103.0 to 159.6/87.5 mmHg; group 2, from 173.6/105.4 to 143.3/86.1 mmHg); decrements in group 1 were minor than those in group 2. A diastolic blood pressure normalization was achieved in 12/15 patients of group 1 and in 10/11 of group 2. Side-effects were rare and of mild severity. Results obtained show that the fixed combination oxprenolol 80 mg plus chlorthalidone 10 mg can be safely administered also in the elderly hypertensive patients, without risk of cardiovascular complications, allowing satisfactory blood pressure control, with a simple dosage schedule, thus improving patient compliance to the therapy.