Zusammenfassung
Akutes Herzversagen stellt mit allein 1 Mio. Fällen/Jahr in den USA ein zentrales medizinisches Problem dar. Während ein Teil der Patienten mit Strategien der Vor- und Nachlastsenkung durch Diuretika und Vasodilatatoren gut rekompensiert werden kann, stellt die Gruppe mit schwerer hämodynamischer Kompromittierung und weiter bestehender Hypoperfusion ein besonderes Problem dar (90 Tage Mortalität: 15 %). Zur Überwindung dieser Akutsituation wird der i. v. Einsatz von positiv inotropen Substanzen notwendig. Derzeit stehen als Inotropika Adrenorezeptor-Agonisten (Dopamin, Dobutamin, Noradrenalin, Adrenalin), Phosphodiesterase III Inhibitoren (Milrinon, Enoximon) und Ca2+-Sensitizer (Levosimendan) zur Verfügung. Der kurzfristigen hämodynamischen Verbesserung der ersten beiden Gruppen steht die Steigerung des myokardialen Sauerstoffverbrauchs, proarrhythmische Effekte und möglicherweise mittelfristig eine Exzessmortalität gegenüber. Dieses Review beleuchtet den Stellenwert der einzelnen Substanzen im Therapiekonzept des akuten Herzversagens und gibt einen Ausblick auf Neuentwicklungen wie Myosin-Aktivatoren und Na+/K+-ATPase-Inhibitoren.
Abstract
Acute heart failure syndromes (AHFS) are a growing health problem in Western Countries. Standard treatment includes vasodilators and diuretics, however, the subgroup of patients with AHFS and low cardiac output state represents a special therapeutic challenge that is complicated by high in-hospital and post-discharge mortality and by requiring additional i. v. inotropic support. The current inotropes in use are adrenoreceptor agonists (dopamine, dobutamine, norepinephrine, epinephrine), phosphodiesterase III inhibitors (milrinone, enoximone), and Ca2+ sensitizers (levosimendane). While most inotropes yield short-term haemodynamic improvements, they are associated with increased myocardial oxygen consumption, (supra-) ventricular arrhythmias and possibly increased post-discharge mortality. This review highlights current inotropes used in the treatment of AHFS and introduces new drug developments including myosin activators and Na+/K+ ATPase inhibitors.
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Prof. Dr. med. Karl Stangl
Universitätsmedizin Berlin, Medizinische Klinik und Poliklinik mit Schwerpunkt Kardiologie und Angiologie, Charité Campus Mitte
Charitéplatz 1
10098 Berlin
Email: karl.stangl@charite.de
