THE AHCPR CLINICAL-PRACTICE GUIDELINE FOR HEART-FAILURE REVISITED

OBJECTIVE: To review the Agency for Health Care Policy and Research (A HCPR) clinical practice guideline for heart failure and comment on the guideline regarding pharmacotherapy from the perspective of the lates t clinical trial data and the authors' clinical experience. DATA SOURC ES: A MEDLINE search (1966 to June 1997) of English-language literatur e pertaining to the pharmacotherapy of heart failure was performed. Sp ecial emphasis was placed on literature published in the last 5 years, Additional literature was obtained from reference lists of key articl es identified through the search. DATA SYNTHESIS: Pertinent clinical t rials were reviewed and considered along with information from the aut hors' database of over 800 patients with heart failure. Evidence conce rning the use of angiotensin-converting enzyme inhibitors at appropria te dosages in all New York Heart Association classes of heart failure and the inclusion of digoxin as part of triple therapy in all symptoma tic patients with left ventricular systolic dysfunction are reviewed, Strategies to circumvent clinical problems that may limit the proper a pplication of standard therapeutic agents are considered, and the poss ible future role of P-blockers as therapeutic agents in patients with heart failure is discussed. CONCLUSIONS: The AHCPR guideline provides the clinician with an excellent framework for treating the patient wit h heart failure. Building on the fundamentals of the guideline, the cl inician can carefully apply current therapy at appropriate dosages and in the best combinations to individualize and thereby optimize pharma cologic therapy for this patient population.