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Nesiritide in cardiovascular anesthesia

Purpose of review Acute heart failure has become a major medical issue in the western population. Because mortality is still as high as 50%, the treatment of these patients has been the focus of many studies. A new approach has recently been proposed, including B-type natriuretic peptide as a medication. The purpose of this review is to discuss these new developments. Recent findings Recent studies have shown that plasma levels of B-type natriuretic peptide may serve as a marker for the severity of acute decompensated heart failure. Nesiritide, which is the recombinant equivalent of B-type natriuretic peptide, is a vasodilator, acting by increasing cyclic guanosine 3′, 5′-monophosphate in the vascular smooth muscle cells. It is mainly considered to be an alternative for nitroglycerin, because it has fewer side-effects, and its activity is more prolonged. Treatment with nesiritide has shown fewer arrhythmias and a lower mortality rate compared with dobutamine and milrinone. In cardiac surgery, nesiritide is mainly administered to patients awaiting heart transplantation, but intraoperatively the doses of nesiritide and anesthetics must be adjusted because of a potential interaction. A few anecdotal reports have shown the advantageous effects of nesiritide in the early post-bypass period. Summary Anesthesiologists will be confronted with increasing numbers of patients with heart failure, who require new forms of medication. Nesiritide is a promising new tool, and its application, which is still mainly restricted to the preoperative period, will probably soon be extended to the early post-bypass period. Abbreviations BNP: B-type natriuretic peptide; NPR: natriuretic peptide receptor; PCWP: pulmonary capillary wedge pressure; VAMC: Vasodilation in the Management of Acute Congestive Heart Failure (study).