Abstract
Decompensated heart failure (HF) may be defined as sustained deterioration of at least one New York Heart Association functional class, usually with evidence of sodium retention. Episodes of decompensation are most commonly precipitated by sodium retention, often associated with medication noncompliance. Our therapeutic approach to hospitalized patients is based on the documented hemodynamic responses to vasodilator therapy, with redistribution of mitral regurgitant flow to forward cardiac output and decompression of the left atrium. Invasive hemodynamic monitoring is seldom required for the effective management of patients with HF and there are risks associated with pulmonary artery catheterization.
The currently available parenteral vasoactive drugs for decompensated heart failure include: (i) vasodilators such as nesiritide, nitroprusside and nitroglycerin (glyceryl trinitrate); (ii) catecholamine inotropes, primarily dobutamine; and (iii) inodilators such as milrinone, a phosphodiesterase inhibitor.
Vasodilators are most appropriate for those patients who are primarily volume-overloaded, but with adequate peripheral perfusion. In this class of agents, nesiritide (recombinant human B-type natriuretic peptide) offers advantages over currently available drugs. Nesiritide produces rapid and sustained decreases in right atrial and pulmonary capillary wedge pressures, with reduction in pulmonary and systemic vascular resistance and increases in cardiac index. The hemodynamic effects of nesiritide infusion were sustained over a duration of 1 week and the drug may be used without intensive monitoring in patients with decompensated HF.
Treatment with dobutamine is indicated in patients in whom low cardiac output rather than elevated pulmonary pressure is the primary hemodynamic aberration. However, milrinone reduces left atrial congestion more effectively than dobutamine, and is well tolerated and effective when used in patients receiving β-blockers.
In-patient therapy for decompensated HF is a short term exercise for symptom relief and provides an opportunity to re-assess management in the continuum of care.
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References
Diller PM, Smucker DR, David B. Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics. J Fam Pract 1999; 48: 177–9
Evangelista LS, Doering LV, Dracup K. Usefulness of a history of tobacco and alcohol use in predicting multiple heart failure readmissions among veterans. Am J Cardiol 2000; 86: 1339–42
Marius-Nunez AL, Heaney L, Fernandez RN, et al. intermittent inotropic therapy in an outpatient setting: a cost-effective therapeutic modality in patients with refractory heart failure. Am Heart J 1996; 132: 805–8
Bennett SJ, Hustler GA, Baker SL, et al. Characterization of the precipitants of hospitalization for heart failure decompensation. Am J Crit Care 1998; 7: 168–74
Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190–5
Williams JF, Bristow MR, Fowler NB, and the Committee on Evaluation and Management of Heart Failure. Guidelines for the evaluation and management of heart failure. Circulation 1995; 92: 2764–84
Senni M, Rodeheffer RJ, Tribouilloy CM, et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol 1999; 33: 164–70
Ashton CM, Kuykendall DH, Johnson ML, et al. The association between the quality of in-patient care and early readmission. Ann Intern Med 1995; 122: 415–21
Francis GS, Benedict C, Johnstone DE, et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure: a substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation 1990 Nov; 82(5): 1724–9
Benedict CR, Johnstone DE, Weiner DH, et al. for the SOLVD Investigators. Relation of neurohumoral activation to clinical variables and degree of left ventricular dysfunction: a report from the Registry of Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1994; 23: 1410–20
Francis GS, Siegel RM, Goldsmith SR, et al. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure: activation of the neurohumoral axis. Ann Intern Med 1985; 103: 1–6
Stevenson LW. Tailored therapy before transplantation for treatment of advanced heart failure: effective use of vasodilators and diuretics. J Heart Lung Transplant 1991; 10: 468–76
Strauss RH, Stevenson LW, Dadourian BA, et al. Predictability of mitral regurgitation detected by Doppler echocardiography in patients referred for cardiac transplantation. Am J Cardiol 1987; 59: 892–4
Weiland DS, Konstam MA, Salem DN, et al. Contribution of reduced mitral regurgitant volume to vasodilator effect in severe left ventricular failure secondary to coronary artery disease or idiopathic dilated cardiomyopathy. Am J Cardiol 1986; 58: 1046–50
Stevenson LW, Brunken RC, Belil D, et al. Afterload reduction with vasodilators and diuretics decreases mitral regurgitation during upright exercise in advanced heart failure. J Am Coll Cardiol 1990; 15: 174–80
Conti JB, Mills RM. Mitral regurgitation and death while awaiting cardiac transplantation. Am J Cardiol 1993; 71: 617–8
Bernard GR, Sopko G, Cerra F, et al. Pulmonary artery catheterization and clinical outcomes: National Heart Lung and Blood Institute and Food and Drug Administration Workshop Report. Consensus Statement. JAMA 2000; 283: 2568–72
Murdoch SD, Cohen AT, Bellamy MC. Pulmonary artery catheterization in critically ill patients. Br J Anaesth 2000: 85: 611–5
Ivanov R, Allen J, Calvin JE. The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters: a meta-analysis. Crit Care Med 2000; 28: 881–2
Harrison DG, Bates JN. The nitrovasodilators: new ideas about old drugs. Circulation 1993; 87: 1461–7
Hobbs RE, Mills RM. Therapeutic potential of nesiritide (recombinant b-type natriuretic peptide) in the treatment of heart failure. Exp Opin Investig Drugs 1999; 8: 1063–72
Mills RM, Hobbs RE, Young JB. ‘BNP’ for heart failure: role of nesiritide in cardiovascular therapeutics. Congestive Heart Failure. In press
Mills RM, LeJemtel TH, Horton DP, et al. Sustained hemodynamic effects of an infusion of nesiritide (human b-type natriuretic peptide) in heart failure: a randomized, double-blind, placebo-controlled clinical trial. Natrecor Study Group. J Am Coll Cardiol 1999 Jul; 34(1): 155–62
Colucci WS, Elkayam U, Horton DP, Abraham WT, Nesiritide Study Group, et al. Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated congestive heart failure. N Engl J Med 2000 Jul 27; 343: 246–53
Young, JB. Vasodilation in the Management of Acute Congestive Heart Failure (VMAC) study results [oral presentation]. 73rd Scientific Sessions of the American Heart Association; 2000 Nov 12–15; New Orleans.
Loh E. Maximizing management of patients with decompensated heart failure. Clin Cardiol 2000; 23 Suppl. III: 1–5
Lowes BD, Simon MA, Tsvetkova TO, et al. Inotropes in the beta-blocker era. Clin Cardiol 2000; 23 Suppl. III: 11–6
Leier CV, Binkley PF. Parenteral inotropic support for advanced congestive heart failure. Prog Cardiovasc Dis 1998; 41: 207–24
Stanek EJ, Kinky DE, Loh E, et al. Cost minimization analysis of milrinone vs. dobutamine treatment strategies as a bridge to heart transplant [abstract]. J Card Fail 1999; 5 Suppl.: 280A
Mills RM, Cunningham MS. Long-term hemodynamic responses to vasodilator therapy in patients with severe left ventricular dysfunction. Am J Cardiol 1999; 84: 939–41
Rosenberg P, Yancy CW. Noninvasive assessment of hemodynamics: an emphasis on bioimpedance cardiography. Curr Opin Cardiol 2000; 15: 151–5
McIntyre KM, Vita JA, Lambrew CT, et al. A noninvasive method of predicting pulmonary-capillary wedge pressure. N Engl J Med 1992; 327: 1715–20
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Mills, R.M., Hobbs, R.E. Drug Treatment of Patients with Decompensated Heart Failure. Am J Cardiovasc Drugs 1, 119–125 (2001). https://doi.org/10.2165/00129784-200101020-00005
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DOI: https://doi.org/10.2165/00129784-200101020-00005