▸ Digoxin. This drug has no impact on mortality, but it does appear to improve symptoms. Dr. Goldberg cautioned that digoxin carries a high risk of renal insufficiency and an increased risk of drug interactions. “Therefore, we limit the use of digoxin only to patients with symptomatic heart failure,” he said.
He recommends using the lowest possible dose of the drug and maintaining drug levels below 1.0 ng/mL.
A recent study of heart failure patients found that digoxin had no effect on quality of life, compared with placebo, in terms of perceived health, physical functioning, depression, anxiety, anger, and the 6-minute walk test (J. Card. Fail. 2003;9:4–12).
▸ Aldosterone antagonists. Trials of these agents show improved mortality for class IIIB or class IV patients, but not in heart failure patients with less severe disease, Dr. Goldberg said.
The role of these drugs with β-blockers is not well defined, and they are contraindicated if patients are on both an ACE inhibitor and an ARB due to a risk of hyperkalemia.
▸ Nitrates. The Vasodilator-Heart Failure Trial (V-HeFT) demonstrated that nitrates in combination with hydralazine are not as effective as ACE inhibitors, yet they are better than placebo.
The African-American Heart Failure Trial (A-HeFT) showed that nitrates and hydralazine improved mortality when used with ACE inhibitors and β-blockers, but their value when added to traditional therapy is unknown in other racial groups.