EDITORIAL / - Blockade - rational or irrational therapy for congestive heart failure ?

CLINICAL AND BASIC RESEARCH in the arena of congestive heart failure is intensive. Nevertheless, accepted treatment modalities for patients with this debilitating and fatal disease are limited to just three: digitalis, diuretics, and vasodilators, and only the latter has been demonstrated to improve survival in patients with congestive heart failure.1 Although cardiac transplantation markedly restores the patient's functional capacity and reduces mortality in patients with symptomatic congestive heart failure, it is expensive, limited to selected patients, and commits the patient to the many risks of long-term immunosuppression. Recent evidence now suggests that /3-blockers may represent a new treatment modality that may not only improve symptoms of heart failure in some patients but reduce mortality and improve left ventricular function as well. Since the concept of administering /3-blocking agents to patients with congestive heart failure runs contradictory to long-established teaching, I will review some of the evidence that they in fact do work and discuss some potential mechanisms of their action. The early proponents of administering /3-blocking agents to patients with congestive heart failure, specifically those with dilated cardiomyopathy, were those in the Swedish group from the University of Goteborg. These investigators reported their experience in 1975 after having administered /3-blockers to seven patients with advanced cardiomyopathies who had resting tachycardias and symptoms refractory to conventional medical therapy.2 They were motivated to do this because of favorable results that they had observed in patients with acute myocardial infarctions complicated by tachycardia and heart failure. These patients with dilated cardiomyopathy noted improvements in their symptoms, their exercise capacity improved as measured by treadmill testing, and reductions in their heart size were documented by echocardiography and serial chest x-rays.