Heart failure decompensated

In theory, one could utilise GC-A ligands to lower blood pressure and to reduce blood volume as they increase the excretion of water and salt. Nesiritide, human recombinant BNP, is the first member of this new class of drugs approved for the initial intravenous treatment of acutely decompensated congestive heart failure. Whether nesiritide can be a valuable addition to the standard therapy of decompensated heart failure remains to be demonstrated. 

Both carvedilol and labetalol are contraindicated in patients with hypersensitivity to the drag, bronchial asthma, decompensated heart failure, and severe bradycardia The drugs are used cautiously in patients with drag-controlled congestive heart failure, chronic bronchitis, impaired hepatic or cardiac function, in those with diabetes, and during pregnancy (Category C) and lactation. 

DiDomenico RJ, Park HY, Southworth MR, et al. Guidelines for acute decompensated heart failure treatment. Ann Pharmacother 2004 38 649-660. 

The most serious side effects of P-blocker administration early in ACS are hypotension, bradycardia, and heart block. While initial, acute administration of P-blockers is not appropriate for patients who present with decompensated heart failure, initiation of P-blockers maybe attempted before hospital discharge in the majority of patients following treatment of acute heart failure. P-Blockers are continued indefinitely. 

Adverse effects and contraindications of calcium channel blockers are described in Table 5-2. Verapamil, diltiazem, and first-generation dihydropyridines should also be avoided in patients with acute decompensated heart failure or left... 

Although P-blockers should be avoided in patients with decompensated heart failure from left ventricular systolic dysfunction complicating an MI, clinical trial data suggest that it is safe to initiate P-blockers prior to hospital discharge in these patients once heart failure symptoms have resolved.64 These patients may actually benefit more than those without left ventricular dysfunction.65 In patients who cannot tolerate or have a contraindication to a P-blocker, a calcium channel blocker can be used to prevent anginal symptoms, but should not be used routinely in the absence of such symptoms.2,3,62... 

Intravenous diltiazem can be used cautiously for up to 24 hours in patients with non-decompensated heart failure, bpm, beats per minute CCB, calcium channel blocker (diltiazem or verapamil) HF, heart failure LV, left ventricular LVEF, left ventricular ejection fraction. 

FIGURE 8-2. General treatment algorithm for acute decompensated heart failure (ADHF) based on clinical presentation. IV vasodilators that may be used include nitroglycerin, nesiritide, or nitroprusside. Metolazone or spironolactone may be added if the patient fails to respond to loop diuretics and a second diuretic is required. IV inotropes that may be used include dobutamine or milrinone. (D/C, discontinue HF, heart failure SBP, systolic blood pressure.) (Reprinted and adapted from J Cardiac Fail, Vol 12, pages el-el 22, copyright 2006, with permission from Elsevier.)... 

Blockers are contraindicated in patients with decompensated heart failure unless it is caused solely by tachycardia (high output). Other contraindications include sinus bradycardia, concomitant therapy with monoamine oxidase inhibitors or tricyclic antidepressants, and patients with spontaneous hypoglycemia. Side effects include nausea, vomiting, anxiety, insomnia, lightheadedness, bradycardia, and hematologic disturbances. 

Acute decompensated heart failure, myocarditis, or severe myopathy... 

In an uncontrolled study of 24 patients with acute, decompensated heart failure unresponsive... 

Konstam MA, Czerska B, Bohm M, Oren RM, Sadowski J, Khanal S, Abraham T, Wasler A, Dahm JB, Gavazzi A, Gradinac S, Legrand V, Mohacsi P, Poelzl G, Radovancevic B, Van Bakel AB, Zile MR, Cabuay B, Bartus K, Jansen P. Aortic flow augmentation a pilot study of hemodynamic and renal responses to a novel percutaneous intervention in decompensated heart failure. Circulation 2005 112 3107-3114. 

Dobutamine Betai-selective agonist t increases cAMP synthesis Increases cardiac contractility, output Acute decompensated heart failure intermittent therapy in chronic failure reduces symptoms IV only duration a few minutes Toxicity Arrhythmias. Interactions Additive with other sympathomimetics... 

Dopamine Dopamine receptor agonist higher doses activate 13 and a adrenoceptors Increases renal blood flow higher doses increase cardiac force and blood pressure Acute decompensated heart failure shock IV only duration a few minutes Toxicity Arrhythmias Interactions Additive with sympathomimetics... 

Inamrinone, milrinone Phosphodiesterase type 3 inhibitors decrease cAMP breakdown Vasodilators lower peripheral vascular resistance also increase cardiac contractility Acute decompensated heart failure IV only duration 3-6 h Toxicity Arrhythmias Interactions Additive with other arrhythmogenic agents... 

Givertz MM et al The effects of KW-3902, an adenosine Al-receptor antagonist, on diuresis and renal function in patients with acute decompensated heart failure and renal impairment or diuretic resistance. 3 Am Coll Cardiol 2007 50(16) 1551. [PMID 17936154]... 

Luss H et al Renal effects of ularitide in patients with decompensated heart failure. Am Heart J 2008 155 1012. [PMID 18513512]... 

Abraham WT, Adams KF, Fonarow GC, et al. 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. 2005 46 57-64. 

Kivikko M, Lehtonen L. Levosimendan a new inodila-tory drug for the treatment of decompensated heart failure. Curr Pharm Des. 2005 11 43 5—455. 

Gattis WA, O Connor CM, Gallup DS, Hasselblad V Gheorghiade M, Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure results of the Initiation Management Predischarge Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial, J Am Coll Cardiol 2004 43 1534-1541. 

A 77-year-old woman took captopril 25 mg tds and furosemide 40 mg/day for decompensated heart failure (4). Irbesartan 75 mg/day then replaced captopril, and 3 days later she developed renal insufficiency. Irbesartan was withdrawn and her renal function normalized within 5 days. It was not stated whether her blood pressure also changed. 

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