Intensiv-Medizinische Behandlung der Fortgeschrittenen Herzinsuffizienz

Acute heart failure is not a uniform disease. It ranges from slight acute decompensated heart failure to prolonged cardiogenic shock with high mortality. Additionally, the underlying causes are diverse, but play an important role since rapid causative therapy may be crucial. The present review focuses on therapeutic options of severe decompensation. Medical therapy remains basically unchanged despite various new substances and studies. It encompasses nitrates and loop diuretics of which nitrates are most important. Alternatively, recombinant BNP, nesiritide, may be used in some circumstances, although it is expensive and its superiority over standard therapy remains to be clearly shown. In case of severe hypotension or cardiogenic shock, positive inotropes may be used. Of these, the calcium sensitizer levosimendan provided encouraging results. Still, recent studies were not able to confirm initially seen positive effects on long-term prognosis. In case of severe heart failure refractory to therapy, mechanical support of the left ventricle may be useful. Intra-aortic balloon pump (IABP) is best studied, which could show improved prognosis in acute myocardial infarction complicated by cardiogenic shock in prospective trials. Rapid aggressive action is most important in these severely sick patients. Newer percutaneously implantable devices (TandemHeart®, Impella) are attractive alternatives to IABP, but present limited experience failed to show clear superiority. If (left)ventricular support is required for longer period of time, surgically implantable devices are of use. However, they should only be used as bridge to transplant or less often to recovery, since as destination therapy they are controversial and showed disappointing results so far.