title: Use of noninvasive hemodynamics to aid decision making in the initiation and titration of neurohormonal agents.
abstract: Angiotensin-converting enzyme inhibitors, beta adrenergic blockers, and nesiritide are pharmacologic agents for heart failure with both short- and long-term neurohormonal and hemodynamic effects. Angiotensin-converting enzyme inhibitors and beta adrenergic blockers reduce morbidity and mortality in chronic heart failure. Higher doses may result in better outcomes than lower doses, but concern about hemodynamic tolerance is a major barrier to the initiation and up-titration of these agents. Nesiritide is a newer neurohormonal agent with proven efficacy and safety for use in decompensated heart failure, but appropriate patient selection has been challenging for clinicians. Like vasodilators, nesiritide may be underutilized in heart failure treatment. Impedance cardiography is a newer, noninvasive monitoring technology that can accurately measure hemodynamic parameters. Impedance cardiography is being used with increasing frequency by clinicians to guide therapy in patients with heart failure and has been proposed in heart failure treatment algorithms. Three case reports are presented to illustrate how hemodynamic data using impedance cardiography can be utilized in the initiation and titration of neurohormonal agents.
authors.affiliation: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA. rsummers@pol.net
authors.forename: Richard L
authors.initials: RL
authors.lastname: Summers
authors.forename: Charles W
authors.initials: CW
authors.lastname: Parrott
authors.forename: Cheryl
authors.initials: C
authors.lastname: Quale
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Lewis
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000627:therapeutic use; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D002307:Cardiography, Impedance; D003657:Decision Making; D003937:Diagnosis, Differential; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D017706:Lisinopril / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D045283:Natriuretic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D020097:Natriuretic Peptide, Brain / Q000008:administration & dosage* / Q000627:therapeutic use; D018377:Neurotransmitter Agents / Q000008:administration & dosage / Q000627:therapeutic use; D017186:Titrimetry
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D045283:Natriuretic Agents; D018377:Neurotransmitter Agents; D020097:Natriuretic Peptide, Brain; D017706:Lisinopril