Preparations of oral isosorbide dinitrate and other oral nitrates may be added to digoxin and diuretics and even to the vasodilators mentioned above. Some patients may feel dizzy, however, with drug combination and close supervision by a physician advisable to achieve the best effects.
G. Beta-Blockers
Beta-adrenergic blocking agents play a key role in the management of patients with heart failure and are strongly recommended for the management of New York Heart Association class I–III heart failure. Transmyocardial measurements have documented that the failing human heart is exposed to increased adrenergic activity. Chronic adrenergic activation has adverse effects on the natural course of heart muscle disease. These cardioactive agents block the renin-angiotensin-aldosterone system and aug¬ment atrial and brain natriuretic peptide. Clinicians appear to have forgotten that beta-blockers decrease renin secretion from the juxtaglomerular cells of the kidney, which causes a decrease in angiotensin levels and reduces aldosterone production. Recent randomized clinical trials have shown particular beta-blockers are as beneficial as ACE inhibitors for the treatment of heart failure. (See chapter entitled Beta-Blockers.)

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