PRINCIPLES OF TREATMENT Aggressive treatment of the underlying cardiovascular disease, especially coronary artery disease, valvular heart disease, or hypertension, should be pursued in all cases of systolic ventricular dysfunction. Concurrent with the evaluation of the underlying cause of systolic ventricular dysfunction, specific medical therapy should be commenced to reduce both morbidity and mortality. Treatment strategies common to all patients with systolic dysfunction regardless of the underlying myocardial disorder are discussed below according to the severity of symptoms of heart failure (Table 1). Therapies proven to reduce morbidity and mortality (angiotensinconverting enzyme [ACE] inhibitors and beta-blockers) should be used in all patients with reduced systolic function. Therapies that control symptoms (digoxin, diuretics) but have not been proved to reduce mortality should be guided by symptoms. Nonpharmacologic measures appropriate for all patients with systolic dysfunction are also outlined in Table 1. Revised ACC/AHA practice guidelines for the evaluation and management of chronic heart failure in the adult suggest a new approach to the classification of heart failure that emphasizes both the evolution and progression of the disease. Accordingly, four stages of heart failure have been identified: 1) stage A have heart failure risk factors but have no structural heart disease; 2) stage B refers to
patients with a structural disorder of the heart, but no history of symptoms; 3) stage C are patients with past or present symptoms of heart failure with associated structural disease of the heart; and 4) stage D are patients with end-stage disease who may require specialized treatment strategies (Table 2).