Vasodilators in the treatment of acute heart failure: what we know, what we don't.
Although we have recently witnessed substantial progress in management and outcome of patients with chronic heart failure, acute heart failure (AHF) management and outcome have not changed over almost a generation. Vasodilators are one of the cornerstones of AHF management; however, to a large extent, none of those currently used has been examined by large, placebo-controlled, non-hemodynamic monitored, prospective randomized studies powered to assess the effects on outcomes, in addition to symptoms. In this article, we will discuss the role of vasodilators in AHF trying to point out which are the potentially best indications to their administration and which are the pitfalls which may be associated with their use. Unfortunately, most of this discussion is only partially evidence based due to lack of appropriate clinical trials. In general, we believe that vasodilators should be administered early to AHF patients with normal or high blood pressure (BP) at presentation. They should not be administered to patients with low BP since they may cause hypotension and hypoperfusion of vital organs, leading to renal and/or myocardial damage which may further worsen patients' outcome. It is not clear whether vasodilators have a role in either patients with borderline BP at presentation (i.e., low-normal) or beyond the first 1-2 days from presentation. Given the limitations of the currently available clinical trial data, we cannot recommend any specific agent as first line therapy, although nitrates in different formulations are still the most widely used in clinical practice.
Metra
Marco
M
Department of Experimental and Applied Medicine, University of Brescia, Italy. metramarco@libero.it
Teerlink
John R
JR
Voors
Adriaan A
AA
Felker
G Michael
GM
Milo-Cotter
Olga
O
Weatherley
Beth
B
Dittrich
Howard
H
Cotter
Gad
G
D000208:Acute Disease; D009320:Atrial Natriuretic Factor / Q000494:pharmacology / Q000627:therapeutic use; D001565:Benzoates / Q000494:pharmacology / Q000627:therapeutic use; D004546:Elapid Venoms / Q000494:pharmacology / Q000627:therapeutic use; D019332:Endothelin-1 / Q000037:antagonists & inhibitors; D006333:Heart Failure / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D020097:Natriuretic Peptide, Brain / Q000494:pharmacology / Q000627:therapeutic use; D020098:Natriuretic Peptide, C-Type / Q000494:pharmacology / Q000627:therapeutic use; D009566:Nitrates / Q000494:pharmacology / Q000627:therapeutic use; D010446:Peptide Fragments / Q000494:pharmacology / Q000627:therapeutic use; D011379:Prognosis; D011725:Pyridines / Q000494:pharmacology / Q000627:therapeutic use; D017466:Receptors, Endothelin / Q000187:drug effects; D012065:Relaxin / Q000494:pharmacology / Q000627:therapeutic use; D013777:Tetrazoles / Q000494:pharmacology / Q000627:therapeutic use; D014661:Vasoconstriction / Q000502:physiology; D014665:Vasodilator Agents / Q000627:therapeutic use*
D001565:Benzoates; C542600:CD-NP natriuretic peptide; D004546:Elapid Venoms; D019332:Endothelin-1; D009566:Nitrates; D010446:Peptide Fragments; D011725:Pyridines; D017466:Receptors, Endothelin; D013777:Tetrazoles; D014665:Vasodilator Agents; D020097:Natriuretic Peptide, Brain; D020098:Natriuretic Peptide, C-Type; C480588:BAY 58-2667; C120582:tezosentan; C056452:Ularitide; D009320:Atrial Natriuretic Factor; D012065:Relaxin