CORRESPONDENCE: LETTER TO THE EDITOR
Diagnosis and Management of Chronic Heart Failure
Pablo Aguiar-Souto, MD, FESC*,
Pablo Garcia-Pavia, MD, FESC,
Lorenzo Silva-Melchor, MD, PhD, FESC and
Francisco J. Ortigosa, MD, PhD, FESC
* Department of Cardiology, Puerta de Hierro University Hospital, San Martín de Porres, 4, 28035 Madrid Spain (Email: aguiarsouto{at}hotmail.com).
The American College of Cardiology/American Heart Association (ACC/AHA) 2005 guideline update for the diagnosis and management of chronic heart failure in the adult recently published in the Journal (1) states that the addition of a combination of isosorbide dinitrate and hydralazine to conventional therapy is strongly recommended (class IIa) with a high level of evidence (level A) for patients who have persistent symptoms without making a distinction on the patient’s race.
Although in the complete version of the guideline (available on JACC’s Web site) it is pointed out that, based on the results of the A-HeFT trial (2), there is not enough evidence to extrapolate the results obtained in black people to the general population; neither the abbreviated nor the complete guideline includes this limitation in the recommendations. To avoid misunderstandings, we believe that this fact should explicitly be reported in both the shortened and complete versions of the guideline when the recommendation of adding isosorbide dinitrate and hydralazine to conventional therapy is made.
As pointed out above, the recommendation of adding isosorbide dinitrate and hydralazine is based on only one controlled, randomized trial (2). It is surprising that the effect of the addition of an angiotensin receptor blocker (ARB) in symptomatic patients who are already being treated with conventional therapy, also evaluated only in one controlled, randomized trial (3), has been considered as a class IIb recommendation with a level of evidence B despite the important benefits showed in the CHARM-Added trial (3).
An additional comment concerns the use of nebivolol in heart failure. In the 2005 guideline there is no mention of nebivolol in heart failure treatment. Nebivolol, a beta1 selective blocker with vasodilating properties due to nitric oxide modulation, was tested in the SENIORS trial (4) and extended the evidence of beta-blockers’ benefits to a broad population of elderly patients with heart failure. The effect of nebivolol has been tested only in one trial involving elderly patients, but if other drug therapies are recommended based on one-trial evidence we believe that nebivolol should, at least, be mentioned as an option in elderly patients with heart failure.
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References
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- Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult J Am Coll Cardiol 2005;46:1116-1143.[Free Full Text]
- Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure N Engl J Med 2004;351:2049-2057.[Abstract/Free Full Text]
- McMurray JJ, Ostergren J, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitorsthe CHARM-Added trial. Lancet 2003;362:767-771.[CrossRef][ISI][Medline]
- Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS) Eur Heart J 2005;26:215-225.[Abstract/Free Full Text]
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