Identify patients with systolic dysfunction who could benefit from therapy.

Randomized trial evidence has consistently shown a survival benefit for patients with severe CHF and/or severe systolic dysfunction (LVEF <0.35 to 0.40) treated with ACE inhibitors, beta-blockers, or spironolactone. No mortality benefit has been found with the initiation of digoxin in patients with CHF from LV systolic dysfunction, though digoxin is frequently used in clinical practice. Both ACE inhibitors and beta-blockers have been proven to be beneficial in patients with both mild and more severe CHF. Spironolactone, on the other hand, at this time, has only been studied in patients already on an ACE inhibitor and in patients with severe heart failure. Because of the extensive data supporting the use of both ACE inhibitors and beta-blockers, these agents should be initiated prior to initiation of spironolactone.