Tailoring Heart Failure TherapyEditors: WillenheimerRonnie, SwedbergKarl216 pp Price £49.95 ISBN 1-84184-148-X (h/b) London: Martin Dunitz, 2003
Authors: Andrew Marshall
Journal: Journal of the Royal Society of Medicine (2003)

Management of heart failure consumes as much as 2% of the total health budget. Several classes of drugs improve survival and quality of life, and their use crosses the boundaries of primary, secondary and tertiary care. The novel approach adopted by Willenheimer and Swedberg is to look at different types of patient and to tailor treatment accordingly.

After a chapter on general measures, recognized experts provide short accounts of management in special circumstances—in the elderly, women, pregnancy, chronic renal failure, coronary disease, valvular heart disease, and peripheral vascular disease. Grown-up congenital heart disease is not included, and as a cardiologist with a special interest in this enlarging group of patients I felt that it should have been. Three chapters have a different format and deserve special mention. One describes tailoring of neurohormonal modulating therapy. The recommended approach, which seems to me useful, is as follows. The patient with chronic heart failure is given a trial of angiotensin converting enzyme inhibitor, beta-blocker and spironolactone at the full doses used in trials. If this regimen is tolerated, then subsequently plasma brain natriuretic peptide measurement may be used to help decide whether to increase dosage or to add an angiotensin receptor blocker. If the side-effects prove intolerable, the recommendation is for multidrug therapy at less than full doses rather than a single drug in full dosage. This approach is not yet evidence-based, but it fits in with the recent concept of a low-dose polypill for cardiovascular disease prevention.

Another chapter looks at arrhythmias in heart failure. We are reminded that diuretics increase susceptibility to ventricular arrhythmias and that aldosterone antagonists are protective. In addition to antiarrhythmic medications the text includes implantable defibrillators, ventricular resynchronization with biventricular pacing and use of pacemakers to prevent attacks of atrial fibrillation or tachycardia. All may find an increasing role in management of heart failure in the future.

Finally, there is a chapter on depression in heart failure. I had not given this important subject enough thought. Studies suggest that 18% of patients have major depression and that this figure is even higher in those under 65 (24%). In addition, many others have subclinical depression. In one survey, only one in five patients who met criteria for major depression were prescribed an antidepressant drug. We need to recognize depression in patients with chronic heart failure and treat it effectively. Newer antidepressants, such as the selective serotonin reuptake inhibitors and the noradrenergic serotonergic enhancer mirtazapine, seem safe to use in such patients.

There is a lot of useful information in this book, which flows well despite the many authors. The chapters are short and can be dipped into when needed. I recommend it to any clinician who looks after patients with heart failure.