Newer approaches to the pharmacological management of heart failure.
OBJECTIVE
The treatment of acute heart failure is gaining importance, specifically in the perioperative setting. Increasing evidence shows that established forms of therapy using beta-adrenergic inotropic drugs have no effect on long-term survival; thus, anesthetists and intensive care specialists are focusing on new strategies. This review examines, with respect to the literature of the past year, whether these strategies will gain significance in the perioperative setting.


RESULTS
Owing to its unique efficacy profile, levosimendan, a calcium sensitizer, improves long-term survival in patients with acute heart failure and has been incorporated into the European Society of Cardiology guidelines. Improved heart function without increased oxygen consumption, anti-ischemic effects, no arrhythmogenic effect and positive effects on intestinal perfusion have been described. Despite the positive effects on hemodynamics and symptoms, tezosentan, an endothelin antagonist, did not improve outcome, perhaps due to too high dosages of the drug. Nesiritide, a recombinant brain natriuretic peptide, may represent an alternative to nitroglycerin and dobutamine and possibly have a benefit for survival. No final conclusions can yet be drawn, however. L-NAME, a nitric oxide synthase antagonist, represents a promising new approach for the treatment of cardiogenic shock. The results must be confirmed in large, randomized studies.


CONCLUSIONS
For perioperative treatment of acute heart failure, levosimendan, nesiritide and L-NAME constitute promising alternatives to conventional inotropic and vasodilatory drugs. The strongest evidence for improving outcome is given for levosimendan. According to the present literature, tezosentan does not currently have any significance for treatment of perioperative heart failure.
Rauch
Helmut
H
Department of Anesthesiology, University of Heidelberg, Germany. helmut.rauch@med.uni-heidelberg.de
Motsch
Johann
J
Böttiger
Bernd W
BW
D020013:Calcium Signaling / Q000187:drug effects; D002316:Cardiotonic Agents / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D016232:Endothelins / Q000502:physiology; D004791:Enzyme Inhibitors / Q000627:therapeutic use; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D006835:Hydrazones / Q000627:therapeutic use; D019331:NG-Nitroarginine Methyl Ester / Q000627:therapeutic use; D020097:Natriuretic Peptide, Brain / Q000502:physiology / Q000627:therapeutic use; D019001:Nitric Oxide Synthase / Q000037:antagonists & inhibitors; D011724:Pyridazines / Q000627:therapeutic use; D011725:Pyridines / Q000627:therapeutic use; D000077464:Simendan; D013777:Tetrazoles / Q000627:therapeutic use
D002316:Cardiotonic Agents; D002317:Cardiovascular Agents; D016232:Endothelins; D004791:Enzyme Inhibitors; D006835:Hydrazones; D011724:Pyridazines; D011725:Pyridines; D013777:Tetrazoles; D020097:Natriuretic Peptide, Brain; D000077464:Simendan; C120582:tezosentan; D019001:Nitric Oxide Synthase; D019331:NG-Nitroarginine Methyl Ester