Cardiology clinics
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Review Historical Article
Invasive hemodynamic monitoring the aftermath of the ESCAPE trial.
The Swan-Ganz catheter was developed 35 to 40 years ago for intensive and cardiac care units to allow bedside placement and continuous monitoring and recording of right-sided heart, pulmonary artery, and wedge pressures and reasonably accurate determinations of cardiac output. Considerations for the clinical application of this balloon-tip, flow-directed, multilumen, thermodilution pulmonary artery catheter in the post-ESCAPE era are presented.
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Acute heart failure syndrome (AHFS) is prevalent and costly, and clinical development of pharmacologic therapy remains challenging. Relieving congestion is still the central goal in the decompensated states, although the predominant approach remains the use of intravenous loop diuretics. ⋯ A resurgence of interest in vasodilator therapy has been supported by a better understanding of the pathophysiology of AHFS and the availability of nesiritide and other natriuretic peptides, but long-term clinical outcomes data are lacking and highly debated. Several promising drugs are currently undergoing clinical development for the treatment of AHFS, although many of the clinical challenges remain unresolved.
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The historical choice of angiotensin-converting enzyme (ACE) inhibition as first-line therapy in heart failure is challenged by early activation of the sympathetic system and multiple ways beta blockade (in particular, unselective agents such as carvedilol) may affect cardiac remodeling, its underlying mechanisms, and, hence, progression of heart failure, compared with ACE inhibition. Existing comparisons indicate similar or possible greater efficacy of beta blockade than ACE inhibition. As beta blockade is well tolerated, it could be considered in individual stable patients. However, early combined treatment with both neurohormonal antagonists remains preferable to either neurohormonal antagonist alone and should not be delayed.