Der Internist

, Volume 51, Issue 8, pp 963–974 | Cite as

Diagnostik und Therapie bei akut dekompensierter Herzinsuffizienz und kardiogenem Schock

Schwerpunkt

Zusammenfassung

Infolge der immer älter werdenden Bevölkerung wird es zu einer Zunahme der stationären Aufnahmen wegen akuter kardialer Dekompensation kommen. Häufigste Ursachen sind Flüssigkeitsüberlagerung, unzureichende Medikation, Non-Compliance bei der Einnahme der Medikamente oder Verschlechterung der kardialen Pumpfunktion. Die Dekompensation infolge Flüssigkeitsüberladung kann durch intravenöse Diuretika gebessert werden. Auch Vasodilatatoren und inotrope Medikamente haben Eingang in die Therapiepläne gefunden. Im Rahmen des ADHERE-Registers (Acute Decompensated Heart Failure National Registry) wurden in über 275 Krankenhäusern Patienten mit akut dekompensierter Herzinsuffizienz charakterisiert. Bei diesen Patienten handelt es sich um eine Gruppe mit unterschiedlichen Herzinsuffizienzursachen und Schweregraden, was verschiedene Therapiestrategien im Rahmen der Notfallbehandlung notwendig macht. Gerade bei der Akutbehandlung wird ein interdisziplinäres Vorgehen gefordert, da die Patienten häufig älter sind und unter Komorbiditäten leiden. Da nur wenige Studien effektive Therapiestrategien nachweisen konnten und verschiedene Register gezeigt haben, dass spezifische Medikamente schwere Nebenwirkungen haben können, sind basierend auf der Pathophysiologie neue spezifischere Therapiestrategien für unterschiedliche Formen der akut dekompensierten Herzinsuffizienz notwendig.

Schlüsselwörter

Kardiale Dekompensation Diuretika Nitrate Revaskularisation Levosimendan 

Therapeutic strategies in acute decompensated heart failure and cardiogenic shock

Abstract

As the population of elderly people is increasing, the number of patients requiring hospitalization for acute exacerbations is rising. Traditionally, these episodes of hemodynamic instability were viewed as a transient event characterized by systolic dysfunction, low cardiac output, and fluid overload. Diuretics, along with vasodilator and inotropic therapy, eventually became elements of standard care. In a multicenter observational registry (ADHERE – Acute Decompensated Heart Failure National Registry) of more than 275 hospitals, patients with acute decompensated heart failure were analyzed for their characteristics and treatments options. These data have shown that this population consists of multiple types of heart failure, various forms of acute decompensation, combinations of comorbidities, and varying degrees of disease severity. The challenges in the treatment require multidisciplinary approaches since patients typically are elderly and have complex combinations of comorbidities. So far only a limited number of drugs is currently available to treat the different groups. Over the past years it was shown that even “standard drugs” might be deleterious by induction of myocardial injury, worsening of renal function or increasing mortality upon treatment. Therefore, based on pathophysiology, different types of acute decompensated heart failure require specialized treatment strategies.

Keywords

Cardiac decompensation Diuretics Nitrates Revascularization Levosimendan 

Literatur

  1. 1.
    Abraham WT, Adams KF, Fonarow GC et al (2005) In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol 46:57–64CrossRefPubMedGoogle Scholar
  2. 2.
    Adams KF, Fonarow GC, Emerman CL et al (2005) Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 149:209–216CrossRefPubMedGoogle Scholar
  3. 3.
    Anderson RD, Ohman EM, Holmes DR et al (1997) Use of intraaortic balloon counterpulsation in patients presenting with cardiogenic shock: observations from the GUSTO-I study. J Am Coll Cardiol 30:708–715CrossRefPubMedGoogle Scholar
  4. 4.
    Akhter MW, Aronson D, Bitar F et al (2004) Effect of elevated admission serum creatinine and its worsening on outcome in hospitalized patients with decompensated heart failure. Am J Cardiol 94:957–960CrossRefPubMedGoogle Scholar
  5. 5.
    Bentancur AG, Rieck J, Koldanov R, Dankner RS (2002) Acute pulmonary edema in the emergency department: clinical and echocardiographic survey in an aged population. Am J Med Sci 323:238–243CrossRefPubMedGoogle Scholar
  6. 6.
    Bibbins-Domingo K, Lin F, Vittinghoff E et al (2004) Renal insufficiency as an independent predictor of mortality among women with heart failure. J Am Coll Cardiol 44:1593–1600CrossRefPubMedGoogle Scholar
  7. 7.
    Chen EW, Canto JG, Parsons LS et al (2003): Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock. Circulation 108:951–957CrossRefPubMedGoogle Scholar
  8. 8.
    Chin BS, Conway DS, Chung NA et al (2003) Interleukin-6, tissue factor and von Willebrand factor in acute decompensated heart failure: relationship to treatment and prognosis. Blood Coagul Fibrinolysis 14:515–521CrossRefPubMedGoogle Scholar
  9. 9.
    Costanzo MR, Saltzberg M, O’Sullivan J, Sobotka P (2005) Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol 46:2047–2051CrossRefPubMedGoogle Scholar
  10. 10.
    Cotter G, Kaluski E, Moshkovitz Y et al (2001) Pulmonary edema: new insight on pathogenesis and treatment. Curr Opin Cardiol 16:159–163CrossRefPubMedGoogle Scholar
  11. 11.
    Cotter G, Metzkor E, Kaluski E et al (1998) Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 351:389–393CrossRefPubMedGoogle Scholar
  12. 12.
    Cotter G, Moshkovitz Y, Kaluski E et al (2003) The role of cardiac power and systemic vascular resistance in the pathophysiology and diagnosis of patients with acute congestive heart failure. Eur J Heart Fail 5:443–451CrossRefPubMedGoogle Scholar
  13. 13.
    Cuffe MS, Califf RM, Adams KF Jr et al (2002) Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA 287:1541–1547CrossRefPubMedGoogle Scholar
  14. 14.
    De Backer D, Biston P, Devriendt J et al (2010) Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362:779–789CrossRefGoogle Scholar
  15. 15.
    De Pasquale CG, Dunne JS, Minson RB, Arnolda LF (2005) Hypotension is associated with diuretic resistance in severe chronic heart failure, independent of renal function. Eur J Heart Fail 7:888–891CrossRefGoogle Scholar
  16. 16.
    Ebelt H, Girndt M, Gekle M, Werdan K (2009) Kardiorenaler „Cross talk“ bei akuter Herzinsuffizeinz – neue Therpieansätze? Intensiv Notfallbeh 34:200–206Google Scholar
  17. 17.
    Ezekowitz J, McAlister FA, Humphries KH et al; APPROACH Investigators (2004) The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease. J Am Coll Cardiol 44:1587–1592CrossRefPubMedGoogle Scholar
  18. 18.
    Felker GM, O’Connor CM (2001) Inotropic therapy for heart failure: an evidence-based approach. Am Heart J 142:393–401CrossRefPubMedGoogle Scholar
  19. 19.
    Fuhrmann JT, Schmeisser A, Schulze MR et al (2008) Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction. Crit Care Med 36:2257–2266CrossRefPubMedGoogle Scholar
  20. 20.
    Gandhi SK, Powers JC, Nomeir AM et al (2001) The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med 344:17–22CrossRefPubMedGoogle Scholar
  21. 21.
    Gheorghiade M, De Luca L, Fonarow GC et al (2005) Pathophysiologic targets in the early phase of acute heart failure syndromes. Am J Cardiol 96 (Suppl 6A):11–17GCrossRefGoogle Scholar
  22. 22.
    Gheorghiade M, Gattis Stough W, Adams KF Jr et al (2005) The Pilot Randomized Study of Nesiritide Versus Dobutamine in Heart Failure (PRESERVD-HF). Am J Cardiol 96 (Suppl 6A):18–25GCrossRefGoogle Scholar
  23. 23.
    Giles TD, Quiroz AC, Roffidal LE et al (1991) Prolonged hemodynamic benefits from a highdose bolus injection of human atrial natriuretic factor in congestive heart failure. Clin Pharmacol Ther 50:557–563CrossRefPubMedGoogle Scholar
  24. 24.
    Gottlieb SS, Brater DC, Thomas I et al (2002) BG9719 (CVT-124), an A1 adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy. Circulation 105:1348–1353CrossRefPubMedGoogle Scholar
  25. 25.
    Hochman JS, Sleeper LA, Webb JG et al (2006) Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 295:2511–2515CrossRefPubMedGoogle Scholar
  26. 26.
    Hochman JS, Sleeper LA, Webb JG et al (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 341:625–634CrossRefPubMedGoogle Scholar
  27. 27.
    Hochman JS, Sleeper LA, White HD et al (2001) One-year survival following early revascularization for cardiogenic shock. JAMA 285:190–192CrossRefPubMedGoogle Scholar
  28. 28.
    Koreny M, Geppert A, Wutte M et al (2000) Effects of milrinone on pulmonary gas exchange in catecholamine-dependent heart failure. Am J Cardiol 86:570–573CrossRefPubMedGoogle Scholar
  29. 29.
    Kramer BK, Schweda F, Riegger GA (1999) Diuretic treatment and diuretic resistance in heart failure. Am J Med 106:90–96CrossRefPubMedGoogle Scholar
  30. 30.
    Krumholz HM, Chen YT, Wang Y et al (2000) Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J 139:72–77CrossRefPubMedGoogle Scholar
  31. 31.
    Lee CR, Watkins ML, Patterson JH et al (2003) Vasopressin: a new target for the treatment of heart failure. Am Heart J 146:9–18CrossRefPubMedGoogle Scholar
  32. 32.
    Metra M, Nodari S, Aloia A et al (2002) Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure: A randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol. J Am Coll Cardiol 40:1248–1258CrossRefPubMedGoogle Scholar
  33. 33.
    Milo O, Cotter G, Kaluski E et al (2003) Comparison of inflammatory and neurohormonal activation in cardiogenic pulmonary edema secondary to ischemic versus nonischemic causes. Am J Cardiol 92:222–226CrossRefPubMedGoogle Scholar
  34. 34.
    Molloy WD, Dobson K, Girling L et al (1984) Effects of dopamine on cardiopulmonary function and left ventricular volumes in patients with acute respiratory failure. Am Rev Respir Dis 130:396–399PubMedGoogle Scholar
  35. 35.
    Neuberg GW, Miller AB, O’Connor CM et al (2002) Diuretic resistance predicts mortality in patients with advanced heart failure. Am Heart J 144:31–38CrossRefPubMedGoogle Scholar
  36. 36.
    Nieminen MS, Bohm M, Cowie MR et al (2005) Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the task force on acute heart failure of the European Society of Cardiology. Eur Heart J 26:384–416CrossRefPubMedGoogle Scholar
  37. 37.
    Nolan J, Sanderson A, Taddei F et al (1992) Acute effects of intravenous phosphodiesterase inhibition in chronic heart failure: simultaneous pre- and afterload reduction with a single agent. Int J Cardiol 35:343–349CrossRefPubMedGoogle Scholar
  38. 38.
    O’Connor CM, Gattis WA, Uretsky BF et al (1999) Continuous intravenous dobutamine is associated with an increased risk of death in patients with advanced heart failure: insights from the Flolan International Randomized Survival Trial (FIRST). Am Heart J 138:78–86CrossRefGoogle Scholar
  39. 39.
    Ohman EM, Nanas J, Stomel RJ et al (2005) Thrombolysis and counterpulsation to improve survival in myocardial infarction complicated by hypotension and suspected cardiogenic shock or heart failure: results of the TACTICS Trial. J Thromb Thrombolysis 19:33–39CrossRefPubMedGoogle Scholar
  40. 40.
    Porter KE, Turner NA, O’Regan DJ, Ball SG (2004) Tumor necrosis factor alpha induces human atrial myofibroblast proliferation, invasion and MMP-9 secretion: inhibition by simvastatin. Cardiovasc Res 64:507–515CrossRefPubMedGoogle Scholar
  41. 41.
    Prondzinsky R, Lemm H, Swyter M et al (2010) Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndrome. Crit Care Med 38:152–160CrossRefPubMedGoogle Scholar
  42. 42.
    Russ M, Prondzinsky R, Christoph A et al (2007) Hemodynamic improvement following levosimendan treatment in patients with acute myocardial infarction and severe cardiogenic shock. Crit Care Med 35(12):2732–2739CrossRefPubMedGoogle Scholar
  43. 43.
    Russ MA, Prondzinsky R, Carter JM et al (2009) Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan. Crit Care Med 37:3017–3023CrossRefPubMedGoogle Scholar
  44. 44.
    Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K (2005) Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA 293:1900–1905CrossRefPubMedGoogle Scholar
  45. 45.
    Sackner-Bernstein JD, Skopicki H, Aaronson KD (2005) Risk of worsening renal function with nesiritide in patients with acute decompensated heart failure. Circulation 111:1487–1491CrossRefPubMedGoogle Scholar
  46. 46.
    Sanborn TA, Sleeper LA, Webb JG et al (2003) Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial. J Am Coll Cardiol 42:1373–1379CrossRefPubMedGoogle Scholar
  47. 47.
    Schiff GD, Fung S, Speroff T, McNutt RA (2003) Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am J Med 114:625–630CrossRefPubMedGoogle Scholar
  48. 48.
    Schrier RW, Abraham WT (1999) Hormones and hemodynamics in heart failure. N Engl J Med 341(8):577–585CrossRefPubMedGoogle Scholar
  49. 49.
    Sweitzer NK, Yancy CW, Lopatin M, Stevenson LW (2005) Unique features of patients hospitalized with heart failure and truly normal ejection fraction. J Am Coll Cardiol 45 (Suppl A):Abstract 173AGoogle Scholar
  50. 50.
    White HD, Assmann SF, Sanborn TA et al (2005) Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: Results from the Should We Emergently Revascularize Occluded Coronaries For Cardiogenic Shock (SHOCK) trial. Circulation 112:1992–2001CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • M. Buerke
    • 1
  • H. Lemm
    • 1
  • M. Russ
    • 1
  • A. Schlitt
    • 1
  • K. Werdan
    • 1
  1. 1.Universitätsklinik und Poliklinik für Innere Medizin IIIMartin-Luther-Universität Halle-WittenbergHalle/SaaleDeutschland

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