Current Heart Failure Reports

, Volume 16, Issue 1, pp 32–37 | Cite as

Vasodilator Therapies in the Treatment of Acute Heart Failure

  • Daniel B. HoltJrEmail author
  • Peter S. Pang
Emergency Medicine (F Peacock, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Emergency Medicine


Purpose of Review

Vasodilators are commonly recommended to treat acute heart failure (AHF), yet they are infrequently used. This review aims to evaluate the clinical utility of traditional, historical, and novel vasodilators in the treatment of AHF.

Recent Findings

No traditional vasodilator (i.e., nitroglycerin) therapy definitely improves short- or long-term outcomes. Despite repeated efforts to develop new pharmacologic treatments, no novel therapy outperforms traditional management. At the present time, we continue to recommend traditional vasodilators, such as nitroglycerin.


The use of select vasodilators in the treatment of AHF improves hemodynamics and provides short-term relief; however, data regarding long-term benefits is lacking.


Acute heart failure Vasodilator(s) 


Compliance with Ethical Standards

Conflict of Interest

Daniel B. Holt Jr. declares no conflicts of interest.

Peter S. Pang reports grants from AHA, NHLBI, and AHRQ during the conduct of the study; grants from Roche; personal fees, non-financial support, and other from Novartis, BMS, and Trevena; personal fees and non-financial support from Baxter; and other from Orthodiagnostics and Edwards outside the submitted work, and associate editor for JACC Heart failure, and Editorial board for the Journal of Cardiac Failure.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. American Heart Association Council on epidemiology and prevention statistics committee and stroke statistics subcommittee. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492. Scholar
  2. 2.
    Heidenreich PA, Albert NM, Allen LA, American Heart Association Advocacy Coordinating Committee, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Radiology and Intervention, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606–19. Scholar
  3. 3.
    Loehr LR, Rosamond WD, Chang PP, Folsom AR, Chambless LE. Heart failure incidence and survival (from the atherosclerosis risk in communities study). Am J Cardiol. 2008;101(7):1016–22. Scholar
  4. 4.
    Storrow AB, Jenkins CA, Self WH, Alexander PT, Barrett TW, Han JH, et al. The burden of acute heart failure on U.S. emergency departments. JACC Heart Fail. 2014;2(3):269–77. Scholar
  5. 5.
    Wong YW, Fonarow GC, Mi X, Peacock WF IV, Mills RM, Curtis LH, et al. Early intravenous heart failure therapy and outcomes among older patients hospitalized for acute decompensated heart failure: findings from the acute decompensated heart failure registry emergency module (ADHERE-EM). Am Heart J. 2013;166(2):349–56. Scholar
  6. 6.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey de Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2013;62(16):e147–239. Scholar
  7. 7.
    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200. Scholar
  8. 8.
    Acute Heart Failure Syndromes. Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. American College of Emergency Medicine, May, 2007.
  9. 9.
    Alexander P, Alkhawam L, Curry J, Levy P, Pang PS, Storrow AB, et al. Lack of evidence for intravenous vasodilators in ED patients with acute heart failure: a systematic review. Am J Emerg Med. 2015;33(2):133–41. Scholar
  10. 10.
    Collins SP, Storrow AB. Acute heart failure. In: Tintinalli JE, Stapczynski JS, Ma OJ, et al., editors. Tintinalli’s emergency medicine: a comprehensive study guide. New York: McGraw-Hill Education; 2016.Google Scholar
  11. 11.
    Fonarow GC. The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med. 2001;2(Suppl 2):S7–S12.Google Scholar
  12. 12.
    Wakai A, McCabe A, Kidney R, Brooks SC, Seupaul RA, Diercks DB, et al. Nitrates for acute heart failure syndromes. Cochrane Database Syst Rev. 2013;8:CD005151. Scholar
  13. 13.
    Nelson GI, Silke B, Ahuja RC, Hussain M, Taylor SH. Haemodynamic advantages of isosorbide dinitrate over frusemide in acute heart-failure following myocardial infarction. Lancet. 1983;1(8327):730–3.CrossRefGoogle Scholar
  14. 14.
    Verma SP, Silke B, Hussain M, Nelson GIC, Reynolds GW, Richmond A, et al. First-line treatment of left ventricular failure complicating acute myocardial infarction: a randomised evaluation of immediate effects of diuretic, venodilator, arteriodilator, and positive inotropic drugs on left ventricular function. J Cardiovasc Pharmacol. 1987;10(1):38–46.CrossRefGoogle Scholar
  15. 15.
    Beltrame JF, Zeitz CJ, Unger SA, Brennan RJ, Hunt A, Moran JL, et al. Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema. J Card Fail. 1998;4(4):271–9.CrossRefGoogle Scholar
  16. 16.
    Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. 2002;287(12):1531–40 Erratum in: JAMA 2002 Aug 7;288(5):577.Google Scholar
  17. 17.
    Cotter G, Metzkor E, Kaluski E, Faigenberg Z, Miller R, Simovitz A, et al. 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. 1998;351(9100):389–93.CrossRefGoogle Scholar
  18. 18.
    Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50(2):144–52.CrossRefGoogle Scholar
  19. 19.
    Mullens W, Abrahams Z, Francis GS, Skouri HN, Starling RC, Young JB, et al. Sodium nitroprusside for advanced low-output heart failure. J Am Coll Cardiol. 2008;52(3):200–7. Scholar
  20. 20.
    Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med. 2007;49(5):627–69.CrossRefGoogle Scholar
  21. 21.
    Long B, Koyfman A, Gottlieb M. Management of heart failure in the emergency department setting: an evidence-based review of the literature. J Emerg Med. 2018.
  22. 22.
    CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med. 1987;316(23):1429–35.CrossRefGoogle Scholar
  23. 23.
    SOLVD Investigators, Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325(5):293–302.CrossRefGoogle Scholar
  24. 24.
    Annane D, Bellissant E, Pussard E, Asmar R, Lacombe F, Lanata E, et al. Placebo-controlled, randomized, double-blind study of intravenous enalaprilat efficacy and safety in acute cardiogenic pulmonary edema. Circulation. 1996;94(6):1316–24.CrossRefGoogle Scholar
  25. 25.
    O'Connor CM, Starling RC, Hernandez AF, Armstrong PW, Dickstein K, Hasselblad V, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med. 2011;365(1):32–43. Scholar
  26. 26.
    Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA. 2005;293(15):1900–5.CrossRefGoogle Scholar
  27. 27.
    Peacock WF, Chandra A, Char D, Collins S, der Sahakian G, Ding L, et al. Clevidipine in acute heart failure: results of the a study of blood pressure control in acute heart failure-a pilot study (PRONTO). Am Heart J. 2014;167(4):529–36. Scholar
  28. 28.
    • Pang PS, Butler J, Collins SP, et al. Biased ligand of the angiotensin II type 1 receptor in patients with acute heart failure: a randomized, double-blind, placebo-controlled, phase IIB, dose ranging trial (BLAST-AHF). Eur Heart J. 2017;38(30):2364–73. This randomized controlled trial investigated the safety and efficacy of an angiotensin II type I receptor ligand, for use in the treatment of acute heart failure.CrossRefGoogle Scholar
  29. 29.
    Felker GM, Butler J, Collins SP, Cotter G, Davison BA, Ezekowitz JA, et al. Heart failure therapeutics on the basis of a biased ligand of the angiotensin-2 type 1 receptor. Rationale and design of the BLAST-AHF study (biased ligand of the angiotensin receptor study in acute heart failure). JACC Heart Fail. 2015;3(3):193–201. Scholar
  30. 30.
    • Packer M, O'Connor C, McMurray JJV, et al. TRUE-AHF Investigators. Effect of ularitide on cardiovascular mortality in acute heart failure. N Engl J Med. 2017;376(20):1956–64. This randomized controlled trial investigated ularitide, an analogue of the natural vasodilator urodilantin, in the treatment of acute heart failure.CrossRefGoogle Scholar
  31. 31.
    Mitrovic V, Lüss H, Nitsche K, et al. Effects of the renal natriuretic peptide uro- dilatin (ularitide) in patients with decom- pensated chronic heart failure: a double- blind, placebo-controlled, ascending-dose trial. Am Heart J. 2005;150:1239.CrossRefGoogle Scholar
  32. 32.
    Mitrovic V, Seferovic PM, Simeunovic D, Ristic AD, Miric M, Moiseyev VS, et al. Haemodynamic and clinical effects of ularitide in decompensated heart failure. Eur Heart J. 2006;27:2823–32.Google Scholar
  33. 33.
    • Teerlink JR, Cotter G, Davison BA, et al. RELAXin in Acute Heart Failure (RELAX-AHF) Investigators. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial. Lancet. 2013;381(9860):29–39. This randomized controlled trial investigated the effects of serelaxin, a recombinant of human relaxin-2, responsible for hemodynamic changes in pregnancy, in the treatment of acute heart failure.CrossRefGoogle Scholar
  34. 34.
    Conrad KP. Maternal vasodilation in pregnancy: the emerging role of relaxin. Am J Physiol Regul Integr Comp Physiol. 2011;301(2):R267–75. Scholar
  35. 35.
    Teichman SL, Unemori E, Teerlink JR, Cotter G, Metra M. Relaxin: review of biology and potential role in treating heart failure. Curr Heart Fail Rep. 2010;7(2):75–82. Scholar
  36. 36.
    Ponikowski P, Metra M, Teerlink JR, et al. Design of the RELAXin in acute heart failure study. Am Heart J. 2012;163(2):149–55.e1. Scholar
  37. 37.
    RELAXin in acute heart failure-2 - RELAX-AHF-2. American College of Cardiology, May 8, 2017.
  38. 38.
    Collins SP, Pang PS, Lindsell CJ, Kyriacou DN, Storrow AB, Hollander JE, et al. International variations in the clinical, diagnostic, and treatment characteristics of emergency department patients with acute heart failure syndromes. Eur J Heart Fail. 2010;12(11):1253–60. Scholar
  39. 39.
    Novartis heart drug portfolio hit by failed serelaxin study. Reuters, March 22, 2017 us-novartis-heart-idUSKBN16T0QG.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Emergency MedicineIndiana UniversityIndianapolisUSA

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