To the Editor:

We thank Formiga et al for their interest in our article and their comments. To avoid our answer being blurred by our opinion about a subject with which we are very close, we shall just respond with a few clarifications.

Several differences exist between heart failure and other chronic progressive diseases, such as cancer for example. These differences mean that the decisions and attitudes of patients and physicians concerning resuscitation when faced with cardiac arrest vary according to the underlying disease.

During the terminal stage of the final course of heart failure, sudden death can be an alleviation when compared with death due to progression of the disease. Nevertheless, the clinical course in most patients with heart failure is characterized by long periods of stability interspersed with short periods of instability. Although the symptoms during these short periods of instability may be very severe and invalidating, the improvement after the disease has been stabilized with treatment can also be spectacular. Hospitalization for heart failure, therefore, does not always mean that the patient is on the final, inexorably decreasing slope of the disease.

Many of the factors which require a patient with heart failure to be hospitalized are in fact reversible. Cardiac arrest may occur at any time during the course of heart failure. The condition is often associated with an electrically unstable myocardium, rapid loss of electrolytes during diuresis and/or the use of possibly arrhythmogenic drugs.1 The condition does not necessarily, though, lead to the final stage of the disease.

In our article2 we do not show an attitude of being "in favor of resuscitation measures in most (77%) patients." Rather, we illustrate the opinion of the patients themselves with data from the SUPPORT study.3 Of these, 77% stated their wish to be resuscitated if they suffered cardiac arrest. Broadly speaking and despite the small sample size, the data provided by Formiga et al confirm that a majority of patients wish to be resuscitated (60%; 95% CI, 48%-71%). When the patients in the SUPPORT study were interviewed again 2 months later, of the 23% of those who had not wanted resuscitation 40% had changed their mind, whereas of the 77% who had wanted resuscitation, only 19% had changed their mind.

The character of our article in this regard was aimed at highlighting the delicate and changing situation. Thus, we cannot agree more with Formiga et al that perfect communication between the medical team and the patient and the patient's family is very important, and that this communication should be continuous so that these decisions, which are always difficult, are taken in the best possible way.