Management of congestive heart failure: neuroendocrine approach

The term heart failure is a complex of clinical syndromes caused by "neuroendocrine" compensatory responses that are renal, neural, hormonal and hemodynamic in nature. Activation of these multiple systems--as a result of renin, angiotensin II and the action of circulatory catecholamines--causes the release of norepinephrine vasopressin and aldosterone. These responses contribute to the arteriolar constriction and salt and water retention that promote central pooling with an increase in pre- and afterload of the already failing heart, causing deterioration of the congestive heart failure (CHF). Therapy for this clinical syndrome is aimed at reducing both pre- and afterload with vasodilators, which produce a profoundly favorable effect on left ventricular performances. Beta blocking agents, which inhibit the increased sympathetic mediated vasoconstriction, up-regulate beta receptors and thus restore responsiveness to the failing heart. Inotropic agents, such as digitalis and amrinone/milrinone are reserved for patients with dilated failing heart and impaired systolic function; recently a synthetic atrial natriuretic factor has been developed for potential use in CHF. Ultrafiltration is also used in refractory preoperative CHF with cardiac abnormalities. Neuroendocrine responses to CHF are treated today directly by improving central hemodynamic imbalance in these patients.