<International Circulation>: All kinds of end stage structural heart disease can cause heart failure， with the end result being the death of the patient. At the same time， heart failure treatments are limited. Can you outline for us which are the recognized better therapies for heart failure?

    Dr Willenheimer: The basic step in any patient with chronic systolic heart failure is the combination of an ACE-inhibitor and a beta-blocker of course. ACE inhibitors are quite adequately used but the beta-blockers are still severely underused. The second step is where you could add an aldosterone antagonist and/or angiotensin receptor blockers. Sometimes patients are suitable for quadruple therapy where we would contemplate introducing cardiac resynchronization therapy (CRT). That is the traditional order of heart failure treatment， but some patients really cannot tolerate much by way of drugs at all and clinical experience shows that in such patients it can be useful to start with a CRT device and slowly increase drug treatment and this can be quite successful. The order of initiating therapy is very important and we know almost nothing about it and we need to learn much more on how to tailor drug therapy to the individual patient rather than just adding one drug after another according to tradition.

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