Survival of patients with congestive heart failure

Over the past several decades, pharmacologic advances have made it possible to markedly alleviate symptoms in most patients with congestive heart failure. However, the prognosis for these patients remains poor. Five years after the onset of congestive heart failure, only approximately 50% of patients are alive; when cardiac failure develops after myocardial infarction mortality is even higher. Survival rates are only 40% to 60% after 1 year in patients with advanced symptoms who are followed in referral centers. Thirty to fifty percent of deaths are sudden and unexpected. Mortality is highest in patients with severe or progressive symptoms, but it appears to be unrelated to the cause of heart failure or its duration. In general, rate of survival is lowest in patients with the most severe depression of left ventricular function, but no hemodynamic index is capable of providing prognostic information in individual patients. Survival is also reduced in patients with frequent ventricular arrhythmias, marked electrolyte disturbances, and elevated plasma catecholamines, but again, none ofthese measurements are powerful discriminators between survivors and nonsurvivors. A number ofpharmacologic and other interventions have the potential to alter the prognosis of congestive heartfailure, either by improving or perhaps even by worsening survival. The pooled data from several shorttermcontrolled trials have raised the possibility that the angiotensin converting-enzyme inhibitors mayhave a beneficial effect on survival. Most excitingly, the recently completed VA Cooperative Studydemonstrated a beneficial effect of the combination of hydralazine and jsosorbide dinitrate. Whilemany questions related to the value of therapeutic interventions to improve survival will have to befurther addressed in prospective randomized trials, we for the first time can address these issues withthe confidence that a beneficial effect of at least some available agents can be demonstrated in certainpatient populations.