As is well known, heart failure in western countries is increasing in prevalence, places a heavy burden on health budgets (accounting for 1–2% of total health care costs), diminishes considerably quality of life, and notwithstanding major advances in management, has a bleak short-term prognosis. Among the challenges facing clinicians is how best to diagnose heart failure. In some patients this presents no problem, especially when symptoms and physical signs are “textbook”, an underlying cause is obvious and basic, and simple investigations (chest x ray in particular) confirm clinical suspicions. But other patients are more challenging where the presence of obesity or chronic airways disease, for example, can obscure or confuse the clinical picture.

LONG TERM MANAGEMENT OF HEART FAILURE PATIENTS

Once any difficulties regarding the diagnosis of heart failure have been overcome, the question of how best to manage patients in the long term arises. Sad to say, evidence-based guidelines regarding drug treatment (relating to the class of drug and, if in use, the recommended dosage) are not commonly followed in clinical practice. There is evidence that in view of the increasing complexity of pharmacotherapy and the rapid evolution of new interventions (resynchronisation therapy, implantable cardioverter-defibrillators, left ventricular assist devices, for example), patients are best cared for in multidisciplinary specialist heart failure clinics or with careful integration of primary and secondary care. Whatever the clinic setting, attention should be directed to treatment of the underlying disorder (most commonly hypertension or/and coronary artery disease), to correction and avoidance of precipitating factors, to the introduction of non-pharmacological measures including an exercise programme and an educational programme (including dietary advice), and for those who are terminal, to counselling expertise and palliative care.

Regarding drug treatment, there are many areas of uncertainty. For patients whose heart failure results predominantly from diastolic left ventricular diastolic dysfunction, many of whom are elderly, female …