Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Nesiritide in the treatment of acute decompensated heart failure

Wilson S Colucci, MD
Section Editors
Stephen S Gottlieb, MD
James Hoekstra, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Acute decompensated heart failure (HF) is a common and potentially fatal cause of acute respiratory distress. The clinical syndrome is characterized by the development of dyspnea, which is commonly associated with the rapid accumulation of fluid within the lung's interstitial and alveolar spaces due to acutely elevated cardiac filling pressures (cardiogenic pulmonary edema) [1]. Acute decompensated HF can also present as elevated left ventricular filling pressures and dyspnea without pulmonary edema.

Multiple modalities are used in the treatment of acute decompensated HF, including oxygen, diuretics, vasodilators, and, in selected patients, inotropic agents. Nesiritide (recombinant human brain natriuretic peptide, BNP 1-32) is a vasodilator that has undergone clinical trials in patients with acute HF.

The possible role of nesiritide in the management of acute decompensated HF will be reviewed here. General issues related to the management of acute decompensated HF, the pathophysiology and evaluation of patients with this disorder, and the management of chronic systolic and diastolic HF are presented separately. (See "Treatment of acute decompensated heart failure: General considerations" and "Evaluation of acute decompensated heart failure" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)


Although plasma brain natriuretic peptide (BNP) levels are increased in patients with heart failure (HF), such patients are sodium avid and have increased systemic vascular resistance. This apparent paradox may be caused by lack of specificity of commercially available immunoreactive-BNP assays that measure inactive as well as active forms; bioactive BNP 1-32 levels may be low in patients with HF [2]. In addition, patients with HF have high levels of vasoconstrictors, particularly angiotensin II and norepinephrine, which may overcome BNP’s effects. (See "Pathophysiology of heart failure: Neurohumoral adaptations".)

The high level of vasoconstrictors and high systemic vascular resistance and possibly low levels of bioactive BNP in these patients provides the rationale for therapy with vasodilators, such as nesiritide. Infusion of nesiritide at doses of up to 0.1 mcg/kg per min in patients with HF can raise the mean plasma BNP concentration from 700 to 13,000 pg/mL with associated arterial and venous vasodilation [3].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 13, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med 2005; 353:2788.
  2. Niederkofler EE, Kiernan UA, O'Rear J, et al. Detection of endogenous B-type natriuretic peptide at very low concentrations in patients with heart failure. Circ Heart Fail 2008; 1:258.
  3. Marcus LS, Hart D, Packer M, et al. Hemodynamic and renal excretory effects of human brain natriuretic peptide infusion in patients with congestive heart failure. A double-blind, placebo-controlled, randomized crossover trial. Circulation 1996; 94:3184.
  4. Colucci WS, Elkayam U, Horton DP, et al. Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated congestive heart failure. Nesiritide Study Group. N Engl J Med 2000; 343:246.
  5. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA 2002; 287:1531.
  6. O'Connor CM, Starling RC, Hernandez AF, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med 2011; 365:32.
  7. Gottlieb SS, Stebbins A, Voors AA, et al. Effects of nesiritide and predictors of urine output in acute decompensated heart failure: results from ASCEND-HF (acute study of clinical effectiveness of nesiritide and decompensated heart failure). J Am Coll Cardiol 2013; 62:1177.
  8. Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA 2013; 310:2533.
  9. Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA 2005; 293:1900.
  10. Arora RR, Venkatesh PK, Molnar J. Short and long-term mortality with nesiritide. Am Heart J 2006; 152:1084.
  11. Sackner-Bernstein JD, Skopicki HA, Aaronson KD. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation 2005; 111:1487.
  12. Witteles RM, Kao D, Christopherson D, et al. Impact of nesiritide on renal function in patients with acute decompensated heart failure and pre-existing renal dysfunction a randomized, double-blind, placebo-controlled clinical trial. J Am Coll Cardiol 2007; 50:1835.
  13. Wang DJ, Dowling TC, Meadows D, et al. Nesiritide does not improve renal function in patients with chronic heart failure and worsening serum creatinine. Circulation 2004; 110:1620.
  14. Abraham WT, Lowes BD, Ferguson DA, et al. Systemic hemodynamic, neurohormonal, and renal effects of a steady-state infusion of human brain natriuretic peptide in patients with hemodynamically decompensated heart failure. J Card Fail 1998; 4:37.
  15. Nesiritide for decompensated congestive heart failure. Med Lett Drugs Ther 2001; 43:100.
  16. Heublein DM, Huntley BK, Boerrigter G, et al. Immunoreactivity and guanosine 3',5'-cyclic monophosphate activating actions of various molecular forms of human B-type natriuretic peptide. Hypertension 2007; 49:1114.