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Moderne Arzneitherapie in der kardiovaskulären Intensivmedizin

Modern drug therapy in cardiovascular intensive care medicine

  • Arzneimitteltherapie
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Zusammenfassung

Vasoaktive Medikamente und Inotropika sind wichtig beim hämodynamischen Management von Patienten mit kardiogenem Schock, wenn die alleinige Volumengabe zu keiner ausreichenden Durchblutung des Gewebes führt. Bei akuter Herzinsuffizienz wird aktuell eher das Konzept der kardialen Entlastung verfolgt. In diesem Beitrag wird der Einsatz der unterschiedlichen Medikamente auf der Intensivstation bei akuter Herzinsuffizienz und kardiogenem Schock dargestellt. Bei akuter Herzinsuffizienz finden Katecholamine nur noch beim Übergang zum kardiogenen Schock Verwendung. Hier wird viel mehr das Therapiekonzept der ventrikulären Entlastung durch die Gabe von Diuretika, Nitraten, Levosimendan (Inodilatator) oder in Zukunft Serelaxin angestrebt.

Das hämodynamische Management beim kardiogenen Schock erfolgt nach moderater Volumengabe mit Dobutamin zur Steigerung der Inotropie. Können keine ausreichenden Perfusionsdrücke erzielt werden, wird Noradrenalin gegeben. Sollte weiterhin keine suffiziente Steigerung der Herzleistung erreicht werden, kann die Gabe des Inodilatators Levosimendan erfolgen. Levosimendan ist hierbei Phosphodiesterase-Hemmern vorzuziehen. Die Maxime des hämodynamischen Managements beim kardiogenen Schock ist der passagere Einsatz der Inotropika und Vasopressoren in der geringsten notwendigen Dosis und nur solange wie notwendig. Dies bedeutet, dass kontinuierlich geprüft werden muss, ob die Dosis reduziert werden kann. Bislang gibt es keine Mortalitätsdaten, die den Nutzen eines hämodynamischen Monitorings anhand von Zielkriterien belegen – für einen sparsamen und rationalen Einsatz von Inotropika und Vasopressoren ist es aber sinnvoll.

Abstract

Vasoactive drugs and inotropes are important in the hemodynamic management of patients with cardiogenic shock despite modest volume administration. Currently, the concept of cardiac relief is pursued in the treatment of acute heart failure. In this article we present the use of different drugs in the intensive care unit for acute heart failure and cardiogenic shock. In acute heart failure catecholamines are only used during the transition from heart failure to cardiogenic shock. Here, the therapeutic concept of ventricular unloading is more sought after. This can be achieved by the use of diuretics, nitrates, levosimendan (inodilatator), or in the future serelaxin.

The hemodynamic management in cardiogenic shock occurs after moderate volume administration with dobutamine to increase inotropy. If no adequate perfusion pressures are achieved, norepinephrine can be administered as a vasopressor. If there is still no sufficient increase in cardiac output, the inodilatator levosimendan can be used. Levosimendan instead of phosphodiesterase inhibitors in this case is preferable. The maxim of hemodynamic management in cardiogenic shock is the transient use of inotropes and vasopressors in the lowest dose possible and only for as long as necessary. This means that one should continuously check whether the dose can be reduced. There are no mortality data demonstrating the utility of hemodynamic monitoring based on objective criteria—but it makes sense to use inotropes and vasopressors sparingly.

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Literatur

  1. Adams KF Jr, Fonarow GC, Emerman CL et al; ADHERE Scientific Advisory Committee and Investigators (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 149:209–216

    Article  Google Scholar 

  2. Cleland JG, Teerlink JR, Senior R et al (2011) The effects of the cardiac myosin activator, omecamtiv mecarbil, on cardiac function in systolic heart failure: a double-blind, placebo-controlled, crossover, dose-ranging phase 2 trial. Lancet 378:676–683

    Article  CAS  PubMed  Google Scholar 

  3. Colucci WS, Elkayam U, Horton DP et al (2000) Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated congestive heart failure. Nesiritide Study Group. N Engl J Med 343:246–253

  4. Cotter G, Dittrich HC, Weatherley BD et al (2008) The PROTECT pilot study: a randomized, placebo-controlled, dose-finding study of the adenosine A1 receptor antagonist rolofylline in patients with acute heart failure and renal impairment. J Card Fail 14:631–640

  5. 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 351:389–393

    Article  CAS  PubMed  Google Scholar 

  6. Cotter G, Kaluski E, Milo O et al (2003) LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock: a prospective randomized study. Eur Heart J 24:1287–1295

    Article  Google Scholar 

  7. 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 287:1541–1547

    Article  CAS  PubMed  Google Scholar 

  8. Delle Karth G, Buberl A, Geppert A et al (2003) Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines. Acta Anaesthesiol Scand 47:1251–1256

    Article  Google Scholar 

  9. Erdmann E, Semigran MJ, Nieminen MS et al (2013) Cinaciguat, a soluble guanylate cyclase activator, unloads the heart but also causes hypotension in acute decompensated heart failure. Eur Heart J 34:57–67

    Article  Google Scholar 

  10. Felker GM, Lee KL, Bull DA et al (2011) Diuretic strategies in acute decompensated heart failure. N Engl J Med 364:797–805

  11. Felker GM, O’Connor CM, Braunwald E (2009) Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil? Circ Heart Fail 2:56–62

    Article  PubMed Central  PubMed  Google Scholar 

  12. Felker GM, Pang PS, Adams KF et al (2010) Clinical trials of pharmacological therapies in acute heart failure syndromes: lessons learned and directions forward. Circ Heart Fail 3:314–325

    Article  PubMed  Google Scholar 

  13. Fonarow GC, Adams KF Jr, Abraham WT et al (2005) Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 293:572–580

    Article  CAS  PubMed  Google Scholar 

  14. Garg V, Frishman WH (2013) A new potential approach to inotropic therapy in the treatment of heart failure: urocortin. Cardiol Rev 21:160–165

    Article  PubMed  Google Scholar 

  15. Gheorghiade M, Pang PS (2009) Acute heart failure syndromes. J Am Coll Cardiol 53:557–573

  16. Hasenfuss G, Teerlink JR (2011) Cardiac inotropes: current agents and future directions. Eur Heart J 32:1838–1845

    Article  Google Scholar 

  17. Hochman JS (2003) Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm. Circulation 107:2998–3002

    Article  PubMed  Google Scholar 

  18. 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 341:625–634

  19. Hogg KJ, McMurray JJ (2010) Evaluating dyspnoea in acute heart failure: progress at last! Eur Heart J 31:771–772

    Article  Google Scholar 

  20. Jolly S, Newton G, Horlick E et al (2005) Effect of vasopressin on hemodynamics in patients with refractory cardiogenic shock complicating acute myocardial infarction. Am J Cardiol 96:1617–1620

    Article  CAS  PubMed  Google Scholar 

  21. Lapp H, Mitrovic V, Franz N et al (2009) Cinaciguat (Bay 58 2667) improves cardiopulmonary hemodynamics in patients with acute decompensated heart failure. Circulation 119:2781–2788

    Article  CAS  PubMed  Google Scholar 

  22. Lopez A, Lorente JA, Steingrub J et al (2004) Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med 32:21–30

    Article  CAS  PubMed  Google Scholar 

  23. Lüss H, Mitrovic V, Seferovic PM et al (2008) Renal effects of ularitide in patients with decompensated heart failure. Am Heart J 155:1012.e1–8

    Google Scholar 

  24. Malik FI, Hartman JJ, Elias KA et al (2011) Cardiac myosin activation: a potential therapeutic approach for systolic heart failure. Science 331:1439–1443

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Malik FI, Morgan BP (2011) Cardiac myosin activation part 1: from concept to clinic. J Mol Cell Cardiol 51:454–461

  26. Massie BM, O’Connor CM, Metra M et al (2010) Rolofylline, an adenosin-A1-receptor antagonist, in acute heart failure. N Engl J Med 363:1419–1428

  27. McMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 14:803–869

    Article  CAS  PubMed  Google Scholar 

  28. Mebazaa A, Nieminen MS, Packer M et al (2007) Levosimendan vs dobutamine for patients with acute decompensated heart failure: the SURVIVE randomized trial. JAMA 297:1883–1891

    Article  CAS  PubMed  Google Scholar 

  29. Mebazaa A, Pang PS, Tavares M et al (2010) The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study. Eur Heart J 31:832–841

    Article  Google Scholar 

  30. Metra M, Bettari L, Carubelli V, Cas LD (2011) Old and new intravenous inotropic agents in the treatment of advanced heart failure. Prog Cardiovasc Dis 54:97–106

    Article  CAS  PubMed  Google Scholar 

  31. Metra M, Cotter G, Davison BA et al (2013) RELAX-AHF Investigators. Effect of serelaxin on cardiac, renal, and hepatic biomarkers in the Relaxin in Acute Heart Failure (RELAX-AHF) development program: correlation with outcomes. J Am Coll Cardiol 61:196–206

  32. Mitrovic V, Seferovic PM, Simeunovic D et al (2006) Haemodynamic and clinical effects of ularitide in decompensated heart failure. Eur Heart J 27:2823–2832

    Article  Google Scholar 

  33. Nieminen MS, Brutsaert D, Dickstein K et al (2006) EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J 27:2725–2736

    Article  Google Scholar 

  34. Nohria A, Tsang SW, Fang JC et al (2003) Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 41:1797–1804

  35. O’Connor CM, Starling RC, Hernandez AF et al (2011) Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med 365:32–43

  36. Packer M, Colucci W, Fisher L et al (2013) Effect of levosimendan on the short-term clinical course of patients with acutely decompensated heart failure. JACC Heart Fail 1:103–111

    Article  PubMed  Google Scholar 

  37. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF) (2002) Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA 287:1531–1540

    Google Scholar 

  38. Russ M, Prondzinsky R, Reith S et al (2005) Profound hemodynamic improvement following levosimendan in patients with acute myocardial infarction and severe cardiogenic shock. Circulation Suppl 112:II-423

    Google Scholar 

  39. Schwertz H, Muller-Werdan U, Prondzinsky R et al (2004) Katecholamine im kardiogenen Schock: hilfreich, nutzlos oder gefährlich? Dtsch Med Wochenschr 129:1925–1930

    Article  CAS  PubMed  Google Scholar 

  40. Teerlink JR, Cotter G, Davison BA et al; RELAXin in Acute Heart Failure (RELAX-AHF) Investigators (2013) Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial. Lancet 381:29–39

    Article  CAS  PubMed  Google Scholar 

  41. Teerlink JR, Metra M, Felker GM et al (2009) Relaxin for the treatment of patients with acute heart failure (Pre-RELAX-AHF): a multicentre, randomised, placebo-controlled, parallel-group, dose-finding phase IIb study. Lancet 373:1429–1439

    Article  CAS  PubMed  Google Scholar 

  42. Teerlink JR, McDonagh T (2013) ATOMIC-AHF: Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure: results from ATOMIC-AHF. Vorgestellt auf dem Kongress der European Society of Cardiology, 31. August 2013 bis 4. September 2013, Amsterdam, Niederlande. http://www.escardio.org/congresses/esc-2013/congress-reports/Pages/709-ATOMIC-AHF.aspx#.UkufstI3t8E. Zugegriffen: 30. März 2015

  43. Teichman SL, Unemori E, Teerlink JR et al (2010) Relaxin: review of biology and potential role in treating heart failure. Curr Heart Fail Rep 7:75–82

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  44. Triumph Investigators (2007) Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial. JAMA 297:1657–1666

    Article  Google Scholar 

  45. Torre-Amione G, Milo-Cotter O, Kaluski E et al (2009) Early worsening heart failure in patients admitted for acute heart failure: time course, hemodynamic predictors, and outcome. J Card Fail 15:639–644

  46. Yancy CW, Jessup M, Bozkurt B et al (2013) 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. Circulation 128:1810–1852

    Article  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. H. Lemm: Vorträge für Orion-Pharma. M. Buerke: Vorträge für Novartis, Orion-Pharma, Bayer Health Care. S. Dietz und M. Janusch geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Medizinische Klinik II – Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Deutschland

    H. Lemm, S. Dietz, M. Janusch &  M. Buerke

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Correspondence to M. Buerke.

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Lemm, H., Dietz, S., Janusch, M. et al. Moderne Arzneitherapie in der kardiovaskulären Intensivmedizin. Internist 56, 702–712 (2015). https://doi.org/10.1007/s00108-015-3717-9

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