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Congestive Heart Failure
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Additional treatments are based on the cause of pulmonary edema. If there is rapid atrial fibrillation, cardioversion is done. Intravenous beta-blockers, digoxin, or careful use of calcium channel blockers can slow the ventricular rate. Intravenous vasodilators are used for severe hypertension. For acute MI or another acute coronary syndrome, treatments include thrombolysis or direct percutaneous coronary angioplasty, with or without stenting. The fluid status is usually normal before pulmonary edema develops. Therefore, diuretics may be not useful when patients have acute decompensation of chronic HF, and can precipitate hypotension. When systolic BP is lower than 100 mg Hg or there is shock, IV dobutamine and counterpulsation with an intra-aortic balloon pump may be needed. Direct-current cardioversion is used for ventricular or supraventricular tachycardia. Newer drugs are available but do not improve outcomes greatly, and can even be implicated in the death of the patient. These include intravenous BNP (nesiritide), ibopamine, levosimendan, pimobendane, and vesnarinone. Once the patient is stabilized, long-term treatment for HF is started.
Heart failure with reduced ejection fraction in older adults
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
The long-term use of oral phosphodiesterase inhibitors, such as amrinone, milrinone, and vesnarinone, is associated with increased mortality (104,143); thus, these drugs and are not approved for clinical use. Intravenous milrinone is also not associated with significant mortality benefit (144,145). The calcium-sensitizing phosphodiesterase inhibitor levosimendan has been shown to improve hemodynamic function and symptoms in younger patients with decompensated HF (146), but it does not have a mortality benefit compared with dobutamine (147,148). Synthetic catecholamines such as dobutamine or dopamine may also be used intravenously to treat refractory HF symptoms although older HFrEF patients may derive smaller hemodynamic benefits (149).
What prevents cardioprotective drugs from reaching the market?
Published in Expert Review of Clinical Pharmacology, 2018
Fedor Simko, Michaela Adamcova
- Phosphodiesterase inhibitors with prominent positive inotropic effects such as amrinone, milrinone, or vesnarinone consistently increased mortality rate when applied to patients with chronic HF with reduced ejection fraction [11] and are no longer used in this indication. The toxic effect of calcium overload resulting in heart muscle cell damage or fatal dysrhythmia could explain the deleterious effect of positive inotropy in HF patients. Surprisingly, trials with calcium-channel blockers (CCBs) reducing the entrance of calcium ions into heart muscle cells did not show beneficial effect in HF, and are not recommended in symptomatic patients with HF with reduced ejection fraction [7]. The increase in sympathetic tone (in some dihydropyridine CCBs) might contribute to the unsafe profile in patients with HF.