• heart failure
• drug treatment
• angiotensin converting enzyme inhibitors
• β blockers

• ACE, angiotensin converting enzyme
• ANP, atrial natriuretic peptide
• BNP brain natriuretic peptide
• CHF, chronic heart failure
• ET-1, endothelin-1
• ICD, implantable cardioverter-defibrillator
• NEP neutral endopeptidase
• NYHA, New York Heart Association

Though the last decade has seen three major breakthroughs in chronic heart failure (CHF) treatment (with angiotensin converting enzyme (ACE) inhibitors,^1,2 β blockers,^3–5 and spironolactone⁶), the outlook of patients with this condition remains very poor. Even the relatively young, highly selected, patients taking part in clinical trials have a bad prognosis despite the best currently available treatment. For example, 7.2% of the metoprolol group in the MERIT-HF study (that is, patients receiving β blocker, ACE inhibitor, diuretic, and often digoxin treatment) died within one year of follow up and 32% died or were hospitalised at least once.^3,7 In the broader population the outlook of patients with CHF is much worse.⁸ In one part of the UK, 45% of patients died within one year of discharge from their first ever hospital admission with heart failure.⁸ The case fatality rate reached 77% within five years and the medial survival of a man discharged after his first heart failure hospitalisation was only 1.47 years. Not only are mortality and morbidity discouragingly and persistently high, but quality of life remains very impaired and the symptom burden of CHF is great. Clearly, more and/or better treatments are needed.

This is all the more so because the burden of CHF is set to increase substantially in coming years. Because populations are aging and survival from the underlying causes of CHF (coronary heart disease and hypertension) is increasing, the incidence and prevalence of CHF will increase. Indeed, in the UK, the prevalence is expected to increase by about 40% in the next two decades.