Nesiritide acute decompensated heart failure

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.)... 

Keating G, Goa K. Nesiritide—a review of its use in acute decompensated heart failure (Review). Drugs 2003 63 47-70. 

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. 

A much more serious complication of dobutamine therapy is ventricular dysrhythmias. Of 305 patients with acutely decompensated congestive heart failure, 58 were given dobutamine (although it is difficult to ascertain the dose), 44 were given other standard inotropic drugs such as milrinone, and 203 were treated with brain natriuretic peptide (nesiritide, 0.015 or 0.03 micrograms/kg/minute) (9). Of those given dobutamine 7% had sustained ventricular tachycardia, 17% had non-sustained ventricular tachycardia, and 5% had a cardiac arrest. In contrast. 

In the PRECEDENT study, dobutamine was compared with nesiritide (B natriuretic peptide) in patients with acutely decompensated congestive heart failure (15). The primary objective of the study was to assess the risk of ventricular dysrhythmias with the two therapies. Altogether 255 patients (mean age 61 years, 67% men) were randomized to receive dobutamine 5 micrograms/ kg/hour or one of two doses of nesiritide 0.015 or 0.03 micrograms/kg/hour. Dobutamine significantly... 

Burger AJ, Elkayam U, Neibaur MT, Haught H, Ghah J, Horton DP, Aronson D. Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated congestive heart failure receiving dobutamine versus nesiritide therapy. Am J Cardiol 2001 88(l) 35-9. 

Burger AJ, Horton DP, LeJemtel T, Ghali JK, Torre G, Dennish G, Koren M, Dinerman J, Silver M, Cheng ML, Elkayam U Prospective Randomized Evaluation of Cardiac Ectopy with Dobutamine or Natrecor Therapy. Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure the PRECEDENT study. Am Heart J 2002 144(6) 1102-8. 

Nesiritide is a human B-type natriuretic peptide, which binds to the particulate guanylate cyclase receptor of vascular smooth muscle and endothelial cells, leading to dose-dependent reductions in pulmonary capillary wedge pressure and systemic arterial pressure in patients with heart failure. It is indicated in the treatment of patients with acutely decompensated CHF who have dyspnea at rest or with minimal activity. 

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