Nesiritide in perspective: evolving approaches to the management of acute decompensated heart failure

Nesiritide is currently indicated for the management of acute decompensated heart failure defined by the presence of volume overload and dyspnea at rest or with minimal activities. Hypotension and cardiogenic shock are the major contraindications to nesiritide use. The recommended dosing schedule is a 2 micro g/kg bolus followed by a 0.01 micro g/kg/min infusion. Some clinicians, however, opt to begin the infusion at the recommended dose without a loading bolus in nonemergency situations. The average duration of infusion in the Vasodilation in the Management of Acute Congestive Heart Failure (VMAC) trial was approximately 28 hours. Clinical efficacy endpoints included resolution of dyspnea and reduction of volume overload. Appropriate oral drug therapy for heart failure management should be initiated during the nesiritide infusion. The 15-year transition of B-type natriuretic peptide from a newly discovered physiologic entity to clinical use in the diagnosis and treatment of heart failure provides a remarkable example of rapid technological improvement and enhanced clinical understanding. As with most advances, the process of rolling back the frontiers of knowledge has posed even more questions. However, we must not overlook the progress to date, simply because all of the answers are not yet available.