Foreword

In the past decade, a growing number of cardiologists have become concerned about the disparity in attention to clinical trials and guidelines among the different presentations of cardiovascular disease. During this time, the pattern of these discrepancies has become clear. For several decades, ST-segment-elevation acute myocardial infarction had been a focus of clinical trials, resulting in the entry of tens of thousands of patients into randomized trials and, consequently, the establishment of effective therapies that have become standards of care. Similar activity occurred in the field of chronic heart failure, with the subsequent definition of effective patterns of care based on evidence. In contrast, patients with non-ST-segment- elevation acute coronary syndromes and acute heart failure, though seen in large numbers in practice, were rarely entered into clinical trials.

Drs. O'Connor, Stough, Gheorghiade, and Adams were key leaders in calling attention to the deficit of evidence for practice in caring for patients with acute heart failure, and this text is definitive proof of the success of their efforts. Through a series of meetings with thought leaders, government agencies, and leaders in the medical products industry, they have directed attention to the topic of acute heart failure. A similar effort has been underway for non-ST-elevation acute coronary syndromes, with similar results. In both areas, we can now rest assured that the clinical community is convinced of the importance of the problem and the critical necessity of producing evidence through clinical trials and epidemiological studies.

Beginning with the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) trial, a series of studies has now identified a variety of therapies that seem to have little to offer patients with acute heart failure. Other therapies are promising—but as yet unproven—in the acute phase of heart failure. These trials have not only served the purpose of informing the practice community about therapies, but they have also refocused attention on the complexity of the pathophysiology and clinical epidemiology of acute heart failure.

This textbook begins, appropriately, with a definition of the problem, including its scope and epidemiology. The huge number of acute heart failure patients will seem startling to those who have not considered this issue before. However, practitioners who see patients in general medicine or cardiology practice are aware of the onslaught of patients with this problem.

The book then moves on to common complications and comorbid conditions. Given the older age of most patients with acute heart failure, it is not surprising that understanding issues such as renal insufficiency, respiratory insufficiency, diabetes, and stroke is so important in caring for these patients. For the most part, decision-making regarding mechanical complications and arrhythmias in the acute phase of the heart failure admission remains an art rather than a science, but the growing volume of clinical epidemiological studies is producing a clear picture of critical decision points that will be amenable to developing definitive evidence for practice.

The text then provides an in-depth review of the pharmacological therapy for acute heart failure. The lack of proven, effective medical therapies remains a major concern in this arena. Milrinone and dobutamine have fallen into disfavor due to negative or unfavorable studies, while many other medications, such as nesiritide and endothelin antagonists, have shown promising but unproven benefit. The good news is that major clinical outcome studies are under way evaluating both of these exciting new therapies.

A particularly interesting twist in this book is the focus on integrative care of the patient. The chapters on psychosocial aspects, nursing care, and disease management clarify many critical issues about the total care of the patient and family that are usually ignored or given short shrift in most medical textbooks. These chapters in particular represent the selfless manner in which O'Connor, Stough, Gheorghiade, and Adams have developed teams dedicated to every aspect of the needs of patients with heart failure.

We hope that future editions of this book will document significant progress in the pursuit of evidence upon which to base practice. It has been a pleasure to participate in the development of a new field of cardiology with O'Connor, Stough, Gheorghiade, and Adams. We hope that Managing Acute Decompensated Heart Failure will become an essential companion to practitioners caring for patients with this increasingly common, difficult, and fatal disease.