Acute and Chronic Heart Failure

Withering demonstrated 200 years ago in the year 1784 that "drop sy" could be successfully treated with foxglove extracts. This dis covery eventually led to the scientifically based treatment of heart failure with chemically defined digitalis glycosides. In Germany, particularly, the usefulness of this development was greatly exagger ated and often resulted in the indiscrimate use of digitalis for pa tients with coronary artery disease and its complications. Today, this type of drug intervention is used more sparingly. At the same time, other therapeutic concepts were introduced, particularly that of drug-induced diuresis and the concept of vasodilation. This book is the result of a systematic study of various therapeu tic approaches for the management of heart failure and includes clinical, experimental and theoretical aspects. For more than a de cade, various therapeutic modalities have been clinically evaluated in the setting of acute heart failure managed in the intensive care unit as well as chronic heart failure for inpatient and outpatient therapy. Experience has shown that in certain clinical situations, particu larly the management of acute disease, specific, individual drug in tervention is required and is based on the underlying etiology for heart failure. However, in chronic heart failure, long-term success can only be achieved by the rational combination of treatment mo dalities. The present text is aimed at providing the clinically and scientif ically oriented physician with the pathophysiologic and pharmaco logic background necessary to place into perspective the therapeutic efforts for the management of heart failure.

For more than a de cade, various therapeutic modalities have been clinically evaluated in the setting of acute heart failure managed in the intensive care unit as well as chronic heart failure for inpatient and outpatient therapy.

Acute Heart Failure.- A. Overview.- I. Recent Developments.- II. Systematic Use of Vasodilating Agents.- 1. Milestones.- 2. Present State of the Art.- Literature.- B. Pathophysiology of Heart Failure With Respect to Vasodilation.- I. Definition of Heart Failure.- 1. Acute and Chronic Heart Failure.- 2. Clinical Presentations.- a) Acute Heart Failure.- b) Chronic Heart Failure.- c) New York Heart Association Functional Classification.- II. Hemodynamics in Heart Failure.- 1. Intracardiac Pressures in Heart Failure.- 2. Technique of Measurement.- a) Swan-Ganz Catheter.- b) Left Ventricular Filling Pressure.- c) Right Atrial Pressure.- d) Cardiac Output.- e) Arterial Blood Pressure.- f) Systemic Vascular Resistance.- III. Pathophysiology.- 1. Pumping Performance as a Function of Ejection Impedance.- 2. Sympathetic Adrenergic Mechanisms of Regulation.- 3. Influence of the Renin-Angiotensin-Aldosterone System.- 4. Venoconstriction.- 5. Preload and Afterload.- a) Preload.- b) Afterload.- IV. Therapeutic Concepts in Heart Failure.- 1. Increase of Myocardial Contractility.- a) Digitalis.- b) Catecholamines.- 2. Vasodilating Agents.- a) Unloading Mechanism.- b) Spectrum of Activity.- 3. Regulation of Venous Vasculature in Heart Failure.- a) Significance of the Venous System.- b) Intrinsic Venous Pooling Capacity.- 4. Hemodynamic Effects of Venodilation.- a) Venous Return.- b) Reduction of Filling Pressure.- c) Subendocardial Perfusion.- d) Diastolic Wall Tension.- e) Intrinsic Counterregulation.- 5. Arterial Vasodilation.- 6. Agents with Activity on the Venous and Arterial Side.- 7. Attenuation of Action with Long-Term Treatment.- a) Non-Responders.- b) Intrinsic Counterregulation.- c) Genuine Tolerance.- d) Differences in Response.- Literature.- C. Acute Left Sided Heart Failure.- I. Conventional Therapy.- 1. Is there still an Indication for Digitalis in Acute Heart Failure?.- 2. Diuretics in Acute Heart Failure.- Literature.- D. Therapy of Acute Pulmonary Edema.- I. Etiology of Pulmonary Edema.- II. Hemodynamics in Pulmonary Edema.- III. Clinical Classification of Pulmonary Edema.- IV. Treatment of Pulmonary Edema.- 1. Action of Nitroglycerin.- a) Hemodynamics.- b) Clinical Presentation.- c) Clinical and Practical Experiences.- d) Ease of Administration.- e) Dosage of Nitroglycerin.- f) Non-Responders in Cardiogenic Shock.- g) Influence on Peripheral Edema.- h) Intravenous Administration of Nitroglycerin in Pulmonary Edema.- i) Sequence of Therapeutic Interventions in the Management of Pulmonary Edema.- 2. Role of Diuretics in the Treatment of Pulmonary Edema.- 3. Digitalis in Pulmonary Edema?.- 4. Morphine.- 5. Drug of Choice.- 6. Other Vasodilators for the Treatment of Pulmonary Edema.- a) Sodium Nitroprusside.- b) Phentolamine.- c) Nifedipine.- 7. Positive Pressure Ventilation.- Literature.- E. Left-Sided Heart Failure in Acute Myocardial Infarction.- I. Clinical Presentation.- 1. Physical Findings.- 2. Radiologic Signs.- 3. Hemodynamics.- II. Treatment with Nitroglycerin and Nitrates.- 1. Reasons for Contraindications in the Past.- 2. Origins of Nitroglycerin Therapy in Acute Myocardial Infarction.- 3. Hemodynamic Effects of Nitroglycerin.- a) Sublingual Nitroglycerin.- b) Continuous Intravenous Infusion of Nitroglycerin.- 4. Oral and Intravenous Administration of Isosorbide Dinitrate.- 5. Clinical Effects of Nitrates.- a) Influence on Pain.- b) Reduction of Dyspnea.- 6. Influence on Myocardial Ischemia.- 7. Reduction of Infarct Size.- a) CK and CK-MB Infarct Size.- b) Electrocardiographic Signs of Necrosis.- 8. Indications for Potential Influence on Prognosis.- 9. Influence of Nitrates on Ventricular Ectopy.- 10. Decrease in Bradyarrhythmias.- 11. Dilation of Functionally Narrowed Coronary Artery Stenosis.- 12. Long-Term Follow-Up: Increased Incidence of Angina Pectoris.- 13. Side Effects.- 14. Summary.- III. Therapeutic Intervention in Acute Myocardial Infarction with Left Ventricular Failure Outside the Hospital.- IV. Mecha