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Objective: A cost-effectiveness analysis of high and low doses of the angiotensin-converting enzyme (ACE) inhibitor lisinopril in the treatment of chronic heart failure.Methods: A cost-effectiveness analysis using data from a randomized controlled trial, ATLAS, where 3164 patients with chronic heart failure were allocated to a high-dose (daily target dose 32.5-35 mg) or low-dose strategy (daily target dose 2.5-5.0 mg) of lisinopril. Differential costs were based on resource use data collected in the trial costed using UK unit costs. Cost-effectiveness analysis related differential costs to differential life-years during a 4-year trial follow-up.Results: The mean total number of hospital in-patient days per patient was 18. 5 in the high dose group and 22.5 in the low dose group. Over the whole duration of the trial, the mean (S.D.) daily dose of lisinopril in the high-dose group was 22.5 mg (15.7 mg) compared to 3.2 mg (2.5 mg) in the low-dose group. The mean difference in cost per patient was pound sterling 397 lower in the high-dose group [95% CI (high-dose-low-dose) - pound sterling 1263 to pound sterling 436]. Mean life-years per patient were 0.085 years higher in the high-dose group [95% CI (high-dose-low-dose) -0.0074 to 0.1706). Based on mean costs and life-years, high-dose therapy dominates low-dose (less costly and more effective). Allowing for uncertainty in mean costs and life-years, the probability of high-dose therapy being less costly than low dose was 82%. If a decision maker is willing to pay at least pound sterling 3600 per life-year gained, the probability of high-dose being more cost-effective was 92%.Conclusions: The ATLAS Study showed that the treatment of heart failure with high-doses of lisinopril has a high probability of being more cost-effective than low-dose therapy. [ABSTRACT FROM AUTHOR]

Objective: This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline.Data Sources: Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty.Study Selection: All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed.Data Extraction and Synthesis: Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws.Conclusion: Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting. [ABSTRACT FROM AUTHOR]

Objective: This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction.Data Source: We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. STUDY SELECTION AND DATA SYNTHESIS: Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, < 0.35 to 0.40) and whether clinical outcomes were reported. Studies that reported only intermediate outcomes (eg, hemodynamics) were not reviewed.Conclusion: Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life. [ABSTRACT FROM AUTHOR]

Several reports have suggested that because isosorbide dinitrate and hydralazine have different and additive haemodynamic effects at rest in patients with chronic heart failure, these agents should be administered in combination. Some studies, however, indicate thay they are effective individually as well. Since most patients with heart failure are symptomatic only with activity, we examined the haemodynamic effects of these drugs given individually and in combination, at rest and during upright bicycle exercise. As has been noted previously, at rest isosorbide significantly lowered both ventricular filling pressures and did not change cardiac output; hydralazine increased cardiac output and had only a slight effect on pulmonary capillary wedge pressure; combined treatment produced both beneficial effects. In contrast, during exercise isosorbide dinitrate also raised cardiac output while hydralazine more dramatically lowered the wedge pressure. Combined treatment produced significantly greater improvement in each haemodynamic index than either drug alone, with a resulting 54 per cent increase in exercise cardiac output, and a 33 per cent reduction in exercise wedge pressure. Maximal oxygen consumption increased acutely during combined treatment. These findings suggest that isosorbide dinitrate and hydralazine may each be effective in some patients, but that they are even more beneficial in combination. [ABSTRACT FROM PUBLISHER]