In heart failure therapy a distinction must be made between the treatment for the resultant acute cardiac insufficiency and the treatment for chronic cardiac insufficiency.
Acute cardiac insufficiency denotes disturbance of the heart function which leads to an insufficient supply of the vital organs with blood. The most common cause of acute heart failure is a myocardial ischemia. Further causes of acute cardiac insufficiency are acute myocarditis, cardiomyopathy, and congenital heart disease.
Along with the causal treatment of acute cardiac insufficiency, pharmacologic support with inotropes and beta blockers for circulatory stabilization is often necessary. If there is no improvement of the circulatory status despite treatment with maximal medical and or pharmacologic support, mechanical circulatory support systems may be employed. The choice of the system depends on the condition of the patient, the estimated duration of support as well as local availability. If there is no possibility for cardiac recovery and long wait list times for transplant are expected, implantation of a long-term circulatory support system may be indicated.
The aim of therapy for chronic cardiac insufficiency is to arrest the progression of the disease and thus the mortality rate. It is important to recognize the cause of cardiac insufficiency and to treat this underlying disease as far as possible. For the medical treatment of chronic cardiac insufficiency various pharmacologic agents have been used. Some demonstrably improve the chances of survival (Beta-blocker, ACE inhibitor, AT2 receptor blocker and aldosterone antagonists), others only improve the symptoms (diuretics). Along with the medical therapy for cardiac insufficiency there are invasive therapeutic possibilities that have been employed including surgical myocardical revascularization (stent/bypass surgery) and heart valve repair and or replacement.
Implantable Cardiac Defibrillators (ICD) are an option use for prevention of sudden cardiac arrest as well as biventricular pacemakers for cardiac resynchronization therapy (CRT) for patients with acute and chronic heart failure. ICDs and pacemakers are indicated for use in chronic heart failure patients with life threatening ventricular arrhythmias or atrial tacharrhymthmias or those patietns who are at significant risk for developing atrial tachyarrhythmias.
For advanced cardiac insufficiency, according to NYHA Class III-IV, the indication for implantation of a ventricular assist device should be considered. The indication exists in patients who demonstrate sever cardiac insufficiency despite receiving maximal medicinal therapy. The treatment strategy in most cases is bridging to cardiac transplantation with a mechanical circulatory support device. Depending on the underlying disease, recovery of myocardial function in rare instances may occur, which allows for explantation of the ventricular assist device without transplantation.