Chronic Heart Failure

A. Schneeweiss Although the syndrome of congestive heart failure has been recognized many years ago, the approach for its evaluation and treatment has until recently, been partial and 'fragmentary'. Various aspects of the disease have been treated according to the evaluation tools and therapeutic measures available at each period. This approach resulted in some of the greatest achievements in the management of heart failure but also left many aspects neglected and also resulted in several paradoxes. Examples of the achievements and limitations of the 'fragmentary' ap­ proach are the use of diuretics and hemodynamic measurements. The devel­ opment of diuretics has provided us with an important tool for helping pa­ tients whose predominant problem was edema. The success of diuretics masked the fact that their use may often be hemodynamically unsound and that they may reduce cardiac output. Only many years after their introduction has the use of diuretics found its appropriate place. Hemodynamic monitoring has gone via the same path. The great contribu­ tion of continuous bedside hemodynamic measurements to understanding heart failure resulted in over-usage by many clinicians, who found themselves treating hemodynamic charts rather than patients. It took almost a decade to realize that hemodynamic improvement, even in the chronic setting, does not necessarily mean symptomatic improvement or an increase in exercise capac­ ity.