CIBIS III: what is the optimum order for initiating chronic heart failure medical therapy?

James B Young

This article has no abstract so we have provided the first paragraph of the full text.

An extraordinary amount of attention has been focused on the diagnosis and treatment of HF.^{1, 2} Effective therapies have evolved over the last few decades as morbidity and mortality endpoint clinical trials have given insight into pharmacologic strategies. For certain drug classes such as ACE inhibitors, selected -blockers, and aldosterone antagonists, the data supporting their use are robust.^{3, 4} Indeed, many important questions regarding optimum HF treatment remain unanswered, including the best order in which to administer drugs. Guidelines suggest that patients with CHF should receive ACE inhibition first and then, after uptitration and stabilization, a -blocker.^{1, 2} These recommendations highlight at least two challenges: polypharmacy and the order in which medication should be given. The reason that the most appropriate order of HF drug therapies remains unknown is because the major clinical trials were done in sequential fashion. If the study drug proved better than placebo, and additional studies were confirmatory, the agent would become an integral component of the polypharmacy protocol. The problem that CIBIS III attempts to address is then obvious: which of a -blocker or an ACE inhibitor first is the best strategy to decrease HF-related morbidity and mortality?

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