Hypertensive emergencies include hypertensive encephalopathy, intracranial hemorrhage with hypertension, aortic dissection, acute pulmonary edema with hypertension, acute cardiac ischemia with hypertension, malignant hypertension and severe hypertension after vascular surgery; hypertensive crisis due to pheochromocytoma or occurring during pregnancy is not discussed in this review. Although immediate reduction of blood pressure is necessary in hypertensive emergencies, an excessive decrease may cause stroke, myocardial infarction or visual changes. Most experienced clinicians aim...

Fenoldopam mesylte (Corlopam - Neurex), a peripheral dopamine-1 (DA₁) agonist, has been approved by the FDA for parenteral use in lowering blood pressure. The manufacturer claims that, unlike other parenteral antihypertensive agents, fenoldopam not only lowers blood pressure but also maintains or improves renal function.

Ever-increasing specialization has made it difficult for many physicians to keep up with therapeutic standards in intensive-care units (ICUs). This issue of Treatment Guidelines offers current recommendations for use of cardiovascular drugs in the ICU for treatment of hypertensive emergencies; shock, cardiac arrest or decompensated heart failure; and ventricular arrhythmias.

Vasodilators are widely used for treatment of congestive heart failure (CHF) that has not responded adequately to diuretics and digitalis. Vasodilator drugs redistribute blood volume in patients with heart failure, lowering pressure and reducing volume in the failing left ventricle, which leads to increased cardiac output, decreased pulmonary capillary wedge pressure, and improved exercise tolerance. Since the last Medical Letter review of this subject (Volume 26, page 115, 1984), some additional data have become available.

Carvedilol (Coreg - SmithKline Beecham and Boehringer-Mannheim), a betaadrenergic and alpha-adrenergic blocker approved by the FDA for treatment of hypertension in 1995, but not marketed at that time, has now been approved and marketed for treatment of mild or moderate (NYHA class II or III) heart failure stabilized on other drugs. It is being promoted as an add-on drug that reduces the morbidity and mortality of the disease.

The FDA has approved Entresto (Novartis), an oral fixed-dose combination of the neprilysin inhibitor sacubitril and the angiotensin receptor blocker (ARB) valsartan, to reduce the risk of cardiovascular death and heart failure hospitalization in patients with heart failure with reduced ejection fraction. Sacubitril is the first neprilysin inhibitor to become available in the US.

Some commonly used systemic drugs that may cause pulmonary toxicity are listed in the table below. These adverse effects may sometimes be difficult to distinguish from the underlying disease (JAD Cooper, Jr et al, Am Rev Respir Dis, 133:321, 488, 1986). Pulmonary effects that are part of a generalized reaction or are indirect effects of drugs - on respiratory muscles, for example, or on the immune system - are not included here.

Pharmacologic management of chronic heart failure (HF) is primarily determined by the patient's left ventricular ejection fraction (LVEF) and severity of symptoms. Patients with chronic HF who have an LVEF ≤40% are considered to have heart failure with reduced ejection fraction (HFrEF) and those with an LVEF ≥50% are considered to have heart failure with preserved ejection fraction (HFpEF). Patients with an LVEF of 41-49% have heart failure with mildly reduced or mid-range ejection fraction.

View the Comparison Chart: Some Drugs for HFrEF