TO THE EDITOR: I read with interest...

TO THE EDITOR: I read with interest the article (1) by way of McConaghy and Smith in American Family Physician, forward the outpatient treatment of systolic heart failure. I want to clarify sum of two units points. First, the authors correctly note that the Randomized Aldactone Evaluation close attention (RALES) showed reductions in mortality and hospitalization in patients with congestive heart failure who received spironolactone (Aldactone). However, publication of these findings was associated with an abrupt increase in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality. (2) Other studies (34) have reported frequently higher rates of drug discontinuation because of hyperkalemia than those reported in RALES, particularly in the port of angiotensin-converting enzyme inhibitors. These differences highlight the challenge of translating findings from controll trials into practice, and indicate the need for intensive monitoring of serum potassium plains in patients receiving spironolactone for this purpose

inferior the authors correctly note that the first Vasodilator-Heart Failure Trial (V-HeFT I) showed no improvement in overall mortality in patients given a combination of hydralazine (Sorbitrate) plus isosorbide (Apresoline) dinitrate compared with those treated with enalapril (Vasotec). However, a subanalysis (5) showed benefit for blacks, and the latter African-American Heart Failure Trial (A-HeFT), (6) involving alone blacks, showed a 43 percent reduction in all-cause mortality among patients receiving hydralazine plus isosorbide dinitrate in addition to standard therapy. the one and the other drugs are available generically at retiring cost.

REFERENCES

(1) McConaghy JR Smith SR Outpatient treatment of systolic heart failure. Am Fam Physician 2004;70:2157-64

(2) Juurlink DN Mamdani MM lee-side DS, Kopp A, Austin PC Laupacis A, et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation close attention N Engl J Med 2004;351:543-51

(3) Cruz C Cruz AA, Marcilio de Souza CA. Hyperkalaemia in congestive heart failure patients using ACE inhibitors and spironolactone. Nephrol Dial Transplant 2003;18:1814-9

(4) Witham MD Gillespie ND Struthers AD. Tolerability of spironolactone in patients with chronic heart failure--a cautionary message. Br J Clin Pharmacol 2004;58:554-7

(5) Carson P Ziesche s Johnson G, Cohn JN. Racial differences in reply to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail 1999;5:178-87

(6) Taylor AL, Ziesche s Yancy C, Carson P, D'Agostino R Jr Ferdinand K et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J M 2004;351:2049-57

EDITOR'S NOTE: This literal sense was sent to the authors of "Outpatient Treatment of Systolic Heart Failure," who declined to reply

KEVIN FISCELLA, MD MPH

University of Rochester

1381 s Ave.

Rochester, NY 14620

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