El mal pronóstico que tiene la insuficiencia cardiaca obliga al uso apropiado de los fármacos que han demostrado beneficio. Para obtener el mejor resultado es necesaria la asociación de varios de ellos, pero el pronóstico sombrío que, en el mejor de los casos, sigue teniendo la insuficiencia cardiaca justifica la creación de nuevos fármacos. Éstos deberán tener unas acciones terapéuticas distintas de los fármacos actualmente recomendados, y actuar sobre alteraciones distintas de las neurohumorales dependientes del sistema renina-angiotensina-aldosterona y del sistema simpático.
En cualquier caso, el tratamiento de un determinado enfermo requerirá de un juicio clínico personalizado, sobre todo cuando la mayor parte de ellos (mayores de 70 años, función sistólica conservada y con morbilidad asociada importante) no están representados (y probablemente, por limitaciones metodológicas, no lo estarán nunca) en los ensayos controlados sobre los que se basan las guías de práctica clínica actuales.
Palabras clave
Insuficiencia cardiaca
Pronóstico
Ensayos clínicos
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Bibliografía
[1.]
G. Permanyer-Miralda, N. Soriano, C. Brotons, I. Moral, J. Pinar, P. Cascant, et al.
Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardiaca en un hospital general.
Rev Esp Cardiol, (2002), 55 pp. 571-578
[2.]
K. MacIntyre, S. Capewell, J.W.T. Stewart, J. Chalmers, A. Boyd, A. Finlayson, et al.
Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995.
Circulation, (2000), 102 pp. 1126-1131
[3.]
S. Stewart, K. MacIntyre, D.J. Hole, S. Capewell, J.J. McMurray.
More malignant that cancer? Five-year survival following a first admission for heart failure.
Eur J Heart Failure, (2001), 3 pp. 315-322
[4.]
Lenzen MJ, Boersma E, Scholte OP, Reimer WJ, Balk AH, Komajda M, et al. Under utilization of evidence based drug treatment in patients with heart failure is only partially explained by dissimilarity to patients enrolled in landmark trials: a report from the Euro Heart Survey on Heart Failure J. 2005;26:2706-13.
[5.]
P.A. Poole-Wilson, K. Swedberg, J.G. Cleland, A. Di Lenarda, P. Hanrath, M. Komajda.
Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial.
Lancet, (2003), 362 pp. 7-13
[6.]
M.R. Mehra, P.A. Uber, G.S. Francis.
Heart failure therapy at a cross-road: are there limits to the neurohormonal model?.
J Am Coll Cardiol, (2003), 41 pp. 1606-1610
[7.]
S. Orn, K. Dickstein.
Neurohormonal inhibition in heart failure, is there a limit.
Eur Heart J, (2003), 24 pp. 1705-1706
[8.]
J.T. Peterson.
Matrix metalloproteinase inhibitor development and the remodeling of drug discovery.
Heart Fail Rev, (2004), 9 pp. 63-79
[9.]
L. Gullestad, T. Ueland, J.G. Fjeld, E. Holt, T. Gundersen, K. Breivik, et al.
Effect of thalidomide on cardiac remodeling in chronic heart failure: results of a double-blind, placebo-controlled study.
Circulation, (2005), 112 pp. 3408-3414
[10.]
C.J. Malkin, P.J. Pugh, J.N. West, E.J.R. Ven Beek, T.H. Jones, K.S. Channer.
Testosterone therapy in men with moderate severity heart failure: a double-blind raandomized placebo controlled trial.
Euyr Heart J, (2006), 27 pp. 57-64
[11.]
J.J. McMurray, J. Ostergren, K. Swedberg, C.B. Granger, P. Held, E.L. Michelson, For the CHARM Investigators and Committees, et al.
Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial.
Lancet, (2003), 362 pp. 767-771
[12.]
B. Pitt, P.A. Poole-Wilson, R. Segal, F.A. Martínez, K. Dickstein, A.J. Camm, et al.
Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II.
Lancet, (2000), 355 pp. 1582-1587
[13.]
J.N. Cohn, G. Tognoni, For the Valsartan Heart Failure Trial Investigators.
A randomized trial of the angiotensin-receptor blocker Valsartan in chronic heart failure.
N Engl J Med, (2001), 345 pp. 1667-1675
[14.]
Guidelines for the diagnosis treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis Treatment of Chronic Heart Failure of the European Society of Cardiology.
Eur Heart J., (2005), 26 pp. 1115-1140
[15.]
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult-Summary Article.
J Am Coll Cardiol, (2005), 46 pp. 1116-1143
[16.]
B. Pitt, F. Zannad, W.J. Remme, R. Cody, A. Castaigne, A. Pérez, et al.
The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.
N Engl J Med, (1999), 341 pp. 709-717
[17.]
S Yusuf, M.A. Pfeffer, K. Swedberg, C.B. Granger, P. Held, J.J. McMurray, For the CHARM Investigators, et al.
Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial.
Lancet, (2003), 362 pp. 777-781
[18.]
M. Flather, M. Shibata, A. Coats, D.J. Van Veldhuisen, A. Parkhomenko, J. Borbola, On behalf of the SENIORS Investigators, et al.
Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS).
Eur Heart J, (2005), 26 pp. 215-225
[19.]
F.A. Masoudi, E.P. Havranek, P. Wolfe, C.P. Gross, S.S. Rathore, J.F. Steiner, et al.
Most hospitalized older persons do not meet the enrollment criteria for clinical trials in heart failure.
Am Heart J, (2003), 146 pp. 250-257
[20.]
K. Swedberg, J. Cleland, H. Dargie, H. Drexler, F. Follath, M. Komadja, et al.
The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology: Guidelines for the Diagnosis and Treatment of Chronic Heart Failure: reply [carta].
Eur Heart J, (2005), 26 pp. 2473-2474
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2006. Sociedad Española de Cardiología