There are 3 primary issues that must be considered when treating heart failure (HF) patients with left ventricular (LV) systolic dysfunction: (1) improving symptoms and quality of life, (2) slowing the progression of cardiac and peripheral dysfunction, and (3) reducing mortality. General measures, such as salt restriction, weight loss, lipids control, and other nonpharmacologic measures are addressed in Section 6. Pharmacologic approaches to symptom control, including diuretics, vasodilators, intravenous inotropic drugs, anticoagulants, and antiplatelet agents are discussed at the end of this section.Two classes of agents have become the recommended cornerstone of therapy to delay or halt progression of cardiac dysfunction and improve mortality: angiotensin-converting enzyme (ACE) inhibitors and b-blockers. Even while these agents are underused in the treatment of HF, new classes of agents have been added that show an impact on mortality, complicating decisions about optimal pharmacologic therapy. These include angiotensin receptor blockers (ARBs), aldosterone antagonists, and the combination of hydralazine and an oral nitrate, all of which are considered in the following recommendations. ACE Inhibitors Recommendation 7.1 ACE inhibitors are recommended for routine administration to symptomatic and asymptomatic patients with LVEF #40%. (Strength of Evidence 5 A) ACE inhibitors should be titrated to doses used in clinical trials, as tolerated during concomitant uptitration of b-blockers. (Strength of Evidence 5 C).
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