Christian Werner, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
Michael Böhm, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.

Cardiovascular disease represents a continuum that starts with risk factors such as hypertension and progresses to atherosclerosis, target organ damage, and ultimately to heart failure or stroke. Renin-angiotensin system (RAS) blockade with angiotensin converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers (ARBs) has turned out to be beneficial at all stages of this continuum. Several mechanisms govern the progression of myocardial damage to end-stage chronic heart failure (CHF). Chronic neuroendocrine activation, comprising the RAS, sympathetic nervous system and the release of cytokines, leads to remodelling processes and via forward / backward failure to clinical symptoms of CHF. Therefore, combined RAS inhibition is especially effective to improve neuroendocrine blockade in CHF patients with repetitive cardiac decompensations.
Key words: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin-angiotensin system, chronic heart failure, clinical trials.

Ali Ahmed, MD, MPH, FACC, FAHA, FESC, associate professor, Division of Gerontology, Geriatric Medicine, and Palliative Care, Department of Medicine, School of Medicine and Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; director, Geriatric Heart Failure Clinics, Veterans Affairs Medical Center, Birmingham, AB, USA.

Heart failure (HF) is the leading cause of hospitalization among older adults. Digoxin has been shown to reduce hospitalization due to worsening HF. However, at the commonly prescribed dose of 0.25 mg/day, digoxin does not reduce mortality. New data suggest that at low doses (0.125 mg/day or lower) digoxin not only reduces hospitalization due to HF, but may also reduce mortality. Further, at lower doses, it also reduces the risk of digoxin toxicity and obviates the need for routine serum digoxin level testing. Digoxin in low doses should be prescribed to older adults with symptomatic HF.
Key words: chronic heart failure, older adults, treatment, digoxin, update.