Advances in the treatment of heart failure

The intensive care clinician has available techniques for assessing the six major determinants of left ventricular function in patients with heart failure and therapeutic approaches for optimizing these determinants and restoring ventricular performance. With the objective data provided via the thermodilution pulmonary arterial catheter, the schema in Figure 12 can be used as a framework for the hemodynamic management of unstable patients. When the filling pressure is less than 20 mm Hg and the cardiac index is greater than 2.5 L/min/m2, no active hemodynamic intervention is indicated. If the patient has recurrent angina or significant hypertension, the use of sublingual nitrates or other agents is indicated to reduce the afterload. Patients who have a low stroke volume are candidates for volume expansion. Filling pressures above 24 mm Hg need to be reduced. Patients with acute pulmonary venous hypertension will frequently respond to sublingual nitrates and bedrest. Patients with persistent congestive heart failure will require supplemental diuretics and more powerful vasodilators. The management of severe low cardiac output and cardiogenic shock may required the addition of supplemental catecholamines and, in selected patients, the intra-aortic balloon pump. In addition to optimizing the ventricular preload and afterload, the treatment of rate, rhythm and conduction disturbances, and the correction of hypoxia and metabolic disturbances are essential. Finally, the ideal treatment for the management of heart failure is to prevent or at least limit the injury to the ventricular myocardium and to correct reversible causes contributing to the patient's symptoms.