Vasodilators – Angina and Heart Failure Management

Let's talk about direct vasodilators. Nitrates like nitroprusside and nitroglycerin are often used. And nesiritide is a new drug that is a natriuretic peptide. It causes vasodilation and volume reduction at the same time. We give it as an IV infusion in acute heart failure only. So, they are not used in chronic heart failure patients. Other direct vasodilators include hydralazine and isosorbide dinitrate. You can use one or both in combination. They do reduce mortality in African American patients in a major study that was released in the United States some years ago. Calcium channel blockers are also sometimes used, but not in heart failure. These are more angina type medications. Remember that the dihydropyridine and the non-dihydropyridine drugs differ in that one works on the heart and one doesn't. There is no use in reducing inotropy, so that's not particularly helpful. Peripheral vasodilation can help in terms of calcium channel blockers, but it also causes a reflex tachycardia, so we don't use it as much in heart failure. Loop diuretics are a mainstay in heart failure treatment. I won't go into too much detail about diuretics as a whole because I've discussed them in detail in the hypertension lecture. But to make a long story short, furosemide is probably used the most in acute heart failure, and it can also be used, and easily titrated in chronic heart failure too. If a patient is allergic to furosemide, we sometimes use ethacrynic acid. Other diuretics include the thiazide diuretics like hydrochlorothiazide and indampamide. Indampamide, by some measures, are better tolerated. I personally haven't seen a huge difference between the two. Metolazone is another diuretic agent that is given in acute situations. I discussed this in our hypertension lecture. Go to the hypertension lecture and have a look at the...