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a) Antiarrhythmic agents14 can exert important cardiodepressant and proarrhythmic effects. Of available agents, only amiodarone has been shown not to adversely affect survival.

b) Calcium channel blockers15 can lead to worsening HF and have been associated with a n i n c r e a s e d r i s k o f c a r d i o v a s c u l a r e v e n t s . O f a v a i l a b l e a g e n t s , o n l y a m l o d i p i n e h a s b e e n

shown not to adversely affect survival.

c) Nonsteroidal anti-inflammatory drugs16

can cause sodium retention and peripheral

vasoconstriction and can attenuate the efficacy, and enhance the toxicity, of diuretics and ACE inhibitors.

Drugs Recommended for Routine Use

Most patients with symptomatic left ventricular dysfunction should be routinely managed with a combination of 4 types of drugs: a diuretic, an ACE inhibitor, a beta-adrenergic blocker, and (usually) digitalis (21).

The value of these drugs has been established in numerous large-scale clinical trials, and the evidence supporting a central role for their use is compelling and persuasive.

Patients with evidence of fluid retention should be given a diuretic until a euvolemic state is achieved, and diuretic therapy should be continued to prevent the recurrence of fluid retention.

Even if the patient has responded favorably to the diuretic, treatment with an ACE inhibitor and a beta-blocker should be initiated and maintained in patients who can tolerate them, because they have been shown to favorably influence the long-term prognosis of HF.

Therapy with digoxin may be initiated at any time to reduce symptoms and enhance exercise tolerance.


Diuretics interfere with the sodium retention typical of HF by inhibiting the reabsorption of sodium or chloride at specific sites in the renal tubules.

14 Packer M. Hemodynamic consequences of antiarrhythmic drug therapy in patients with chronic heart failure. J Cardiovasc Electrophysiol 1991;2:S240-7.

15 Packer M, Kessler PD, Lee WH. Calcium-channel blockade in the management of severe chronic congestive heart failure: a bridge too far. Circulation 1987;75:V56-64.

16 Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med 1998;158:1108-12.

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