Skip to main content
NCBI home page
Clinical Cardiology logoLink to Clinical Cardiology
. 2007 Oct 23;31(7):297–301. doi: 10.1002/clc.20251

Management Strategies for Stage‐D Patients with Acute Heart Failure

David Feldman 3,✉, Doron M Menachemi 1, William T Abraham 1, Randell K Wexler 2
PMCID: PMC2692105  NIHMSID: NIHMS117203  PMID: 17957741

Abstract

Heart Failure (HF) accounted for 3.4 million ambulatory visits in 2000. Current guidelines from the American Heart Association/American College of Cardiology, the Heart Failure Society of America, and the International Society for Heart & Lung Transplantation recommend aggressive pharmacologic interventions for patients with HF. This may include a combination of diuretics, Angiotensin Converting Enzyme inhibitors, β‐blockers, angiotensin receptor blockers, aldosterone antagonists, and digoxin. Nitrates and hydralazine are also indicated as part of standard therapy in addition to β‐blockers and Angiotensin Converting Enzyme inhibitors, especially but not exclusively, for African Americans with left ventricular (LV) systolic dysfunction. For those with acute decompensated HF, additional treatment options include recombinant human B‐type natriuretic peptide, and in the future possible newer agents not yet approved for use in the U.S., such as Levosimendan. Medical devices for use in patients with advanced HF include LV assist devices, cardiac resynchronization therapy, and implantable cardioverter defibrillators. For refractory patients, heart transplantation, the gold‐standard surgical intervention for the treatment of refractory HF, may be considered. Newer surgical options such as surgical ventricular restoration may be considered in select patients. Copyright © 2007 Wiley Periodicals, Inc.

Keywords: heart failure, cardiac transplantation, cardiomyopathy, myocarditis

Full Text

The Full Text of this article is available as a PDF (101.6 KB).

References

  • 1. Burt CW, Schappert SM: Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999–2000. Vital Health Stat 2004; 13: 1–78. [PubMed] [Google Scholar]
  • 2. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, et al.: ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the Adult. Circulation 2005; 112: 1825–1852. [Google Scholar]
  • 3. Adams KF, Lindenfeld J, Arnold JMO, Baker DW, Barnard DH, et al.: HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 2006; 12: e1–e122. [DOI] [PubMed] [Google Scholar]
  • 4.Digitalis Investigation Group: The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336: 525–533. [DOI] [PubMed] [Google Scholar]
  • 5. Ahmad A, Rich MW, Love TE, Lloyd‐Jones DM, Aban IB, et al.: Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial. Eur Heart J 2006; 27: 178–186. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Taylor AL, Zieche S, Yancy C, Carson P, D'Agostino R, et al.: Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004; 351: 2049–2057. [DOI] [PubMed] [Google Scholar]
  • 7. Neuberg GW, Miller AB, O'Connor CM, Belkin RN, Carson PE, et al.: Diuretic resistance predicts mortality in patients with advanced heart failure. Am Heart J 2002; 144: 31–38. [DOI] [PubMed] [Google Scholar]
  • 8. Emerman CL, DeMarco T, Costanzo MR, Peacock WF: Impact of intravenous diuretics on the outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE® Registry [abstract 368]. J Card Fail 2004; 10(4, suppl 1): S116–S117. [DOI] [PubMed] [Google Scholar]
  • 9. Domanski M, Norman J, Pitt B, Haigney M, Hanlon S, et al.: Diuretic use, progressive heart failure, and death in patients in the Studies of Left Ventricular Dysfunction (SOLVD). J Am Coll Cardiol 2003; 42: 705–708. [DOI] [PubMed] [Google Scholar]
  • 10. Domanski M, Tian X, Haigney M, Pitt B: Diuretic use, progressive heart failure, and death in patients in the DIG study. J Card Fail 2006; 12: 327–332. [DOI] [PubMed] [Google Scholar]
  • 11. Fonarow GC: Pharmacologic therapies for acutely decompensated heart failure. Rev Cardiovasc Med 2002; 3(suppl 4): S18–S27. [PubMed] [Google Scholar]
  • 12. Elis A, Bental T, Kimchi O, Ravid M, Lishner M: Intermittent dobutamine treatment in patients with chronic refractory congestive heart failure: a randomized, double‐blind, placebo‐controlled study. Clin Pharmacol Ther 1998; 63: 682–685. [DOI] [PubMed] [Google Scholar]
  • 13. Cuffe MS, Califf RM, Adams KFJ, Benza R, Bourge R, et al.: Short‐term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA 2002; 287: 1541–1547. [DOI] [PubMed] [Google Scholar]
  • 14. Mills RM, Hobbs RE, Young JB: ”BNP” for heart failure: role of nesiritide in cardiovascular therapeutics. Congest Heart Fail 2002; 8: 270–273. [DOI] [PubMed] [Google Scholar]
  • 15. Peacock FW, Emerman CL, Diercks DB, Lopatin M, Fonarow GC: Acute heart failure mortality is dependent on time to intravenous vasoactive administration [abstract 386]. J Card Fail 2006; 12(6, suppl 1): S117. [Google Scholar]
  • 16. Franci GS: Vasodilators in the intensive care unit. Am Heart J 1991; 121: 1875–1878. [DOI] [PubMed] [Google Scholar]
  • 17. Cioffi G, Stefenelli C, Tarantini L, Opasich C: Hemodynamic response to intensive unloading therapy (furosemide and nitroprusside) in patients > 70 years of age with left ventricular systolic dysfunction and decompensated chronic heart failure. Am J Cardiol 2003; 92(9): 1050–1056. [DOI] [PubMed] [Google Scholar]
  • 18. Johnson W, Omland T, Hall C, Lucas C, Myken A: Neurohormonal activation rapidly decreases after intravenous therapy with diuretics and vasodilators for class IV heart failure. J Am Coll Cardiol 2002; 39: 1623–1629. [DOI] [PubMed] [Google Scholar]
  • 19. Abraham WT, Lowes BD, Ferguson DA, Odom J, Kim JK, et al.: Systemic hemodynamic, neurohormonal, and renal effects of a steady‐state infusion of human brain natriuretic peptide in patients with hemodynamically decompensated heart failure. J Card Fail 1998; 4: 37–44. [DOI] [PubMed] [Google Scholar]
  • 20. Aronson D, Burger AJ: Effect of nesiritide (human b‐type natriuretic peptide) and dobutamine on heart rate variability in decompensated heart failure. Am Heart J 2004; 148: 920–926. [DOI] [PubMed] [Google Scholar]
  • 21. Sica DA, Gottwald MD, Li Yu‐Ping: Nesiritide appears to inhibit the rise in plasma aldosterone associated with furosemide diuresis [abstract 275]. J Card Fail 2006; 12(6, suppl 1): S85–S86. [Google Scholar]
  • 22. Jensen KT, Carstens J, Pedersen EB: Effect of BNP on renal hemodynamics, tubular function and vasoactive hormones in humans. Am J Physiol 1998; 274: F63–F72. [DOI] [PubMed] [Google Scholar]
  • 23. Michaels AD, Klein A, Chatterjee Ku: Effects of intravenous nesiritide on coronary vasomotor regulation and myocardial oxygen extraction. J Am Coll Cardiol 2003; 41(6): 205. [DOI] [PubMed] [Google Scholar]
  • 24.Publication Committee for the VMAC Investigators: Intravenous nesiritide versus nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA 2002; 287: 1531–1540. [DOI] [PubMed] [Google Scholar]
  • 25. Sackner‐Bernstein JD, Kowalski M, Fox M, Aaronson K: Short‐term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA 2005; 293: 1900–1905. [DOI] [PubMed] [Google Scholar]
  • 26. Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ: Risk stratification for in‐hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 2005; 293: 572–580. [DOI] [PubMed] [Google Scholar]
  • 27. Mentzer RM Jr, Oz MC, Sladen RN, Graeve AH, Hebeler RF, et al.: Effects of perioperative nesiritide in patients with left ventricular dysfunction undergoing cardiac surgery: the NAPA trial. J Am Coll Cardiol 2007; 49(6):Available at: http://content.onlinejacc.org/in_press_ fasttrack.dtl, Accessed December 11, 2006. [DOI] [PubMed] [Google Scholar]
  • 28. Mebazaa A, Nieminem MS, Packer M, Cohen‐Solal A, Kleber FX, et al.: Levosimendan versus Dobutamine for patients with acute decompensated heart failure The SURVIVE Randomized Trial. JAMA 2007; 297: 1883–1891. [DOI] [PubMed] [Google Scholar]
  • 29. Di Donato M, Toso A, Dor V, Sabatier M, Barletta G, et al.: Surgical ventricular restoration improves mechanical intraventricular dyssynchrony in ischemic cardiomyopathy. Circulation 2004; 109: 2536–2543. [DOI] [PubMed] [Google Scholar]
  • 30.National Heart, Lung, and Blood Institute: Surgical Treatment for Ischemic Heart Failure (STICH). National Institute of Health website. Available at: http://www.clinicaltrials.gov/ct/show/NCT00023595. Updated 2005; accessed March 21, 2005.
  • 31. Mehta SM, Pae WE Jr, Rosenberg G, Snyder AJ, Weiss WJ, et al.: The LionHeart LVD‐2000: a completely implanted left ventricular assist device for chronic circulatory support. Ann Thorac Surg 2001; 71: S156–S161. [DOI] [PubMed] [Google Scholar]
  • 32. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, et al.: Long‐term use of a left ventricular assist device for end‐stage heart failure. N Engl J Med 2001; 345: 1435–1443. [DOI] [PubMed] [Google Scholar]
  • 33. Abraham WT, Hayes DL: Cardiac resynchronization therapy for heart failure. Circulation 2003; 108: 2596–2603. [DOI] [PubMed] [Google Scholar]
  • 34. Blanc J‐J, Bertault‐Valls V, Fatemi M, Gilard M, Pennec PY, et al.: Midterm benefits of left univentricular pacing in patients with congestive heart failure. Circulation 2004; 109: 1741–1744. [DOI] [PubMed] [Google Scholar]
  • 35. Bradley DJ, Bradley EA, Baughman KL, Berger RD, Calkins H, et al.: Cardiac resynchronization and death from progressive heart failure: a meta‐analysis of randomized controlled trials. JAMA 2003; 289: 730–740. [DOI] [PubMed] [Google Scholar]
  • 36. Salukhe TV, Dimopoulos K, Francis D: Cardiac resynchronisation may reduce all‐cause mortality: meta‐analysis of preliminary COMPANION data with CONTAK‐CD, InSync ICD, MIRACLE and MUSTIC [editorial]. Int J Cardiol 2004; 93: 101–103. [DOI] [PubMed] [Google Scholar]
  • 37. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, et al.: Cardiac‐resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–2150. [DOI] [PubMed] [Google Scholar]
  • 38. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, et al.: The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–1549. [DOI] [PubMed] [Google Scholar]
  • 39. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, et al.: Amiodarone or an implantable cardioverter‐defibrillator for congestive heart failure. N Engl J Med 2005; 352: 225–237. [DOI] [PubMed] [Google Scholar]
  • 40. Costanzo MR, Saltzberg M, O'Sullivan J, Sobotka P: Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol 2005; 46 2047–2051. [DOI] [PubMed] [Google Scholar]
  • 41. Lopez‐Candales AL, Carron C, Schwartz J: Need for hospice and palliative care services in patients with end‐stage heart failure treated with intermittent infusion of inotropes. Clin Cardiol 2004; 27: 23–28. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES