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Different causes of heart failure need different treatment strategies.

No one would now believe that all infections will respond to a single antibiotic, nor that all known antibiotics should be given to all patients with infection. It is obvious that some patients with specific causes of heart failure need specific treatment, but whether heart failure of ischaemic or nonischaemic origin need different treatments is not certain. Only when parallel clinical trials have been conducted with individual drugs in separate groups of patients with ischaemic or nonischaemic heart failure will the need for different treatment strategies be known. Until then, there will be a dependency on second-rank evidence (that which can be derived from trials with 'surrogate' end-points, from meta-analysis of small trials and from subset analysis of different patient groups within single trials). The best evidence at present comes from subset analysis of two studies, with bisoprolol (Cardiac Insufficiency Bisoprolol Study; CIBIS) and amlodipine (Prospective Randomised Amlodipine Survival Evaluation; PRAISE). These suggest that patients with different causes of heart failure respond to treatment in different ways.