A rational approach for the treatment of acute heart failure: current strategies and future options

Purpose of review Acute decompensated heart failure represents a major, growing health problem in the developed world. However, until recently, relatively little research has been performed in this field to provide a basis for rational treatment strategies. The purpose of this review is to discuss the current approach and the potential future strategies for treatment of patients with acute decompensated heart failure. Recent findings Recent data have confirmed the heterogeneous nature of patients admitted with acute decompensated heart failure, and the limitations of the current therapeutic regimens with diuretics, intravenous vasodilators (ie, nitroglycerin, nitroprusside), and intravenous inotropes (ie, dobutamine, milrinone). A new vasodilator, nesiritide, has been demonstrated to improve hemodynamics and symptoms at 3 hours compared with nitroglycerin, and has been added to the therapeutic armamentarium in the United States. However, none of these agents has been shown to influence patient outcomes favorably. Given the high readmission rates, morbidity, and mortality of acute decompensated heart failure, other newer approaches, such as antagonists to a number of neurohumoral targets (ie, endothelin [tezosentan], vasopressin [conivaptan, tolvaptan], and adenosine) and non-cAMP-mediated inotropy (ie, levosimendan), are currently under investigation and showing promise. Summary Acute decompensated heart failure presents a challenging therapeutic problem for clinicians. Although they readily correct the hemodynamic abnormalities, current treatment strategies have significant limitations and have not been shown to improve morbidity or mortality. A number of new agents are under investigation with the goal of improving patient outcomes.