Beyond angiotensin-converting enzyme inhibitors and β-blockers: Nonpharmacologic therapy for chronic heart failure

PURPOSE: This article reviews nonpharmacologic treatment options for patients with chronic heart failure (HF). EPIDEMIOLOGY: HF is the fastest growing cardiovascular problem in the United States, driven both by the demographics of aging and the partial short-term successes of newer therapies for acute cardiovascular conditions. REVIEW SUMMARY: Though there is still much room for improvement in the appropriate utilization of angiotensin-converting enzyme (ACE) inhibitors and β-blockers in patients with HF, other nonpharmacologic therapies also should be considered. Select HF patients with ejection fractions less than 35% will benefit from implantable cardioverter/defibrillators or biventricular pacemakers. The effects of exercise training currently are being studied. Surgical options for some HF patients include revascularization, valve repair, destination ventricular assist devices, and transplantation. Furthermore, new therapies such as stem cell replacement are undergoing preliminary studies. TYPE OF AVAILABLE EVIDENCE: Randomized, placebo-controlled multicenter clinical trials; retrospective single-center and multicenter surgical outcomes studies; national registry data review; unstructured review. GRADE OF AVAILABLE EVIDENCE: Fair to good. CONCLUSION: Although the β-blockers and ACE inhibitors have the strongest evidence of mortality benefit for the typical HF patient, emerging data from recent clinical trials indicate that clinicians now have other options to help selected HF patients live longer and feel better.