Pharmacological Management of Heart Failure: A Century of Expert Opinions in Cecil Textbook of Medicine

Background Drug therapy for heart failure influences quality of life and work potential of affected persons and has contributed to decrease in hospitalizations and cardiovascular mortality. The current approach is the result of incremental progress in understanding the pathophysiology of the syndrome, introduction of new molecules, and repurposing existing drugs. Study question What are the milestones of the changes in the expert clinicians' approach to the pharmacological management in the past century? Study design To determine the changes in the experts' approach to the management of heart failure, as presented in a widely used textbook in the United States. Data sources The chapters on the management of heart failure in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. Results In 1927, heart failure was treated with powdered leaf or tincture of digitalis, mercury chloride, and theophylline. Patients with acute pulmonary edema received injections of atropine, adrenaline, and ouabain. The therapeutic milestones in heart failure were the introduction of loop diuretics and aldosterone antagonists (1971), vasodilator treatment with hydralazine and nitroglycerine (1979-1985), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and selective beta-adrenergic blockers (1992-2000), and sacubitril-valsartan (2016). For acute pulmonary edema, the durable milestone was the treatment with morphine and furosemide (1971). Conclusions The pharmacological management of heart failure in the past century has progressed in fits and starts, with latent periods between significant advances lasting 8-40 years. In chronological order, the major advances were efficient diuresis, afterload reduction, and blunting the neurohormonal response to hemodynamic stress and cardiac remodeling.