In the three decades that I have been a participant and observer in Cardiology there have been many surprising developments, not less so in the realm of heart failure.
There are a number of medications that have been extremely helpful, and have each decreased heart failure mortality by about 30%. When the heart is failing, a number of hormonal signals are generated that are paradoxically neither protective nor helpful. When I was a student these were identified as protecting blood flow to the kidney, and the ‘wisdom of the body’ was thought to be paramount.
The first of these therapies was the use of ACE inhibition; ACE for angiotensin converting enzyme. As the increase in renin during heart failure was neutralized by these agents, beneficial results included an increase in longevity and well-being. These medications include captopril, the first ACE inhibitor, enalapril, lisinopril, ramipril, and several others. They are occasionally associated with a troublesome cough, resulting in the substitution of their cousins, the ARB group (angiotensin receptor blocker).
The second addition to the armament neutralized an increase in epinephrine seen in the failing heart; this use of beta-blockers added another 30% improvement in mortality. The term beta-blocker refers to the blockade of beta receptors in the heart responsible for heart rate and blood pressure control. The first beta blocker was Inderal (generic as propanolol), followed by longer acting agents, and generally prescribed now as metoprolol (Toprol). A newer cousin, carvedilol, improves on this track record.
The third antagonist is spironolactone, a mineralocorticoid receptor antagonist. A newer molecule is called eplerenone. Medications are generally added sequentially based on response. These medications are nominally for the treatment of hypertension, but are added even in the absence of high blood pressure. If they are slowly increased, a reasonable dose can generally be achieved without side effects.
None of these medications are useful if they are not taken. Keeping a medication log along with a daily weight chart is key in helping to control symptoms.