Emerging and Traditional Treatment in Acute Heart Failure: Bad News from Last Interventional Trials

Over last two decades many drugs and Trials have been tested in order to improve Acute Heart failure (AHF) management and outcome. Despite recent findings showing significant improvements in the pharmacological management of chronic heart failure, in AHF patients no consistent benefits in terms of mortality and re-hospitalization rates have been found. Indeed, heart failure remains one of the leading causes of hospital admission in industrialized countries and relative costs is unacceptably high. Thus a therapeutic optimization and drug titration during hospitalization period to prevent future adverse event is one of the primary goals of treatment. Unfortunately, old and new drugs more recently attempted demonstrated contrasting results. In most of cases additional pharmacological treatment showed a transient improvement of some hemodynamic parameters such as wedge pressure reduction stroke volume improvement and congestion relief. Despite these apparently recover the mid and long term outcome revealed an insufficient trend. This is particularly true in patients in more severe hemodynamic picture, more advanced Heart failure and increased congestion burden. Inconsistent results could be due in part to the attempted drug inefficiency and partially to the study design and protocol that tested the same drug in several HF subtypes. In the light of this negative findings, we support the crucial relevance of emphasizing the heterogeneity through AHF clinical profiles, with different medical needs. Accordingly, in this review we report the main finding of the most important trials performed in AHF and we purpose a reappraisal of some attempted drugs looking for the primary HF deterioration mechanism, and the related prevalent pathophysiological disorder.