Decompensated
heart failure (HF) may be defined as sustained deterioration of at least one New York Heart Association functional class, usually with evidence of
sodium retention. Episodes of decompensation are most commonly precipitated by
sodium retention, often associated with medication noncompliance. Our therapeutic approach to hospitalized patients is based on the documented hemodynamic responses to
vasodilator therapy, with redistribution of mitral regurgitant flow to forward cardiac output and
decompression of the left atrium. Invasive hemodynamic monitoring is seldom required for the effective management of patients with HF and there are risks associated with pulmonary artery catheterization. The currently available parenteral vasoactive drugs for decompensated
heart failure include: (i)
vasodilators such as
nesiritide,
nitroprusside and
nitroglycerin (
glyceryl trinitrate); (ii)
catecholamine inotropes, primarily
dobutamine; and (iii) inodilators such as
milrinone, a
phosphodiesterase inhibitor.
Vasodilators are most appropriate for those patients who are primarily volume-overloaded, but with adequate peripheral perfusion. In this class of agents,
nesiritide (recombinant human
B-type natriuretic peptide) offers advantages over currently available drugs.
Nesiritide produces rapid and sustained decreases in right atrial and pulmonary capillary wedge pressures, with reduction in pulmonary and systemic vascular resistance and increases in cardiac index. The hemodynamic effects of
nesiritide infusion were sustained over a duration of 1 week and the
drug may be used without intensive monitoring in patients with decompensated HF. Treatment with
dobutamine is indicated in patients in whom
low cardiac output rather than elevated pulmonary pressure is the primary hemodynamic aberration. However,
milrinone reduces left atrial congestion more effectively than
dobutamine, and is well tolerated and effective when used in patients receiving beta-blockers. In-patient
therapy for decompensated HF is a short term exercise for symptom relief and provides an opportunity to re-assess management in the
continuum of care.