Advanced congestive heart failure. Inpatient treatment and selection for cardiac transplantation

Establishment of an effective oral medical regimen for a patient with advanced congestive heart failure often requires hospitalization for simultaneous adjustment of volume status and vasodilation. In the hospital, intravenous therapy is begun with nitroprusside sodium (Nipride, Nitropress) and/or nitroglycerin (Nitro-Bid IV, Tridil), combined with intravenous diuretics; it is sometimes necessary to add infusions of dobutamine (Dobutrex) or dopamine hydrochloride (Dopastat, Intropin). After 48 hours of intravenous therapy, most patients can be weaned onto oral vasodilators and eventually discharged. In patients in whom further escalation of therapies is necessary, first intravenous amrinone lactate (Inocor) or milrinone lactate (Primacor) may be added, and then epinephrine or, rarely, norepinephrine (Levophed). Steps beyond that include a trial of intra-aortic balloon counterpulsation, implantation of a mechanical assist device, or use of an external centrifugal pump. Cardiac transplantation is indicated for patients in critical or unstable conditions who have no contraindications to the procedure. The patient's profile for compliance must be carefully evaluated. Reform of the selection process is needed to identify patients who, though not critically ill, will not survive without early transplantation.