Pharmacologic therapies for acutely decompensated heart failure.

The management of acutely decompensated heart failure in the emergency medical setting poses a major clinical challenge. Acutely decompensated heart failure is characterized by hemodynamic abnormalities and neuroendocrine activation that contribute to heart failure symptoms, end-organ dysfunction, arrhythmias, and progressive cardiac failure. The therapeutic goals in patients presenting with acutely decompensated heart failure are to stabilize the patient, reverse acute hemodynamic abnormalities, rapidly reverse dyspnea and/or hypoxemia caused by pulmonary edema, and initiate treatments that will decrease disease progression and improve survival. Pharmacologic therapies to impact the hemodynamic abnormalities and symptoms in patients with acutely decompensated heart failure include diuretics, inotropic agents, vasodilators, and natriuretic peptides. In patients with acutely decompensated heart failure, it has recently been demonstrated that elevation in left ventricular filling pressure is the hemodynamic abnormality that most directly impacts heart failure symptoms and is highly predictive of increased risk of fatal decompensation and sudden death. Measures of systemic perfusion, arterial pressure, and vascular resistance have not been predictive of symptoms or clinical outcomes. An ideal agent for acute decompensated heart failure would be one that rapidly reduces pulmonary wedge pressure, results in balanced arterial and venous dilation, promotes natriuresis, lacks direct positive inotropic effects, and does not result in reflex neuroendocrine activation.