Current Practices and Perspectives on the Use of Intravenous Vasodilators in Acute Heart Failure: An International Survey

Although a solid pathophysiologic rationale supports intravenous vasodilators (IVV) for acute heart failure (AHF), trial evidence is conflicting and international guidelines offer only weak recommendations. We conducted an international survey to capture contemporary, real-world practice and clinician opinion regarding IVV use in AHF. A 29-item, web-based questionnaire was distributed to cardiologists involved in AHF management. Items explored indications, contraindications, preferred agents, monitoring strategies, and interaction with guideline-directed medical therapy. We analyzed responses from 170 physicians in 32 countries (67% male; mostly aged 30-50 years). Sixty-two percent treat <10 patients per month with IVV; nitroglycerin is the drug of choice for 48%, followed by sodium nitroprusside in 29%. Nearly half (48%) would start IVV also out of the intensive-care setting and 58% consider repeated noninvasive blood pressure monitoring sufficient. Key indications are acute decompensated heart failure (88%) and pulmonary edema (87%), yet 42% would also use IVV for advanced low-output HF, 25% for cardiogenic shock, and 24% for isolated right ventricular failure. Hypotension is cited as the principal contraindication (51%), although the reported thresholds for blood pressure vary widely. Respondents favor IVV in reduced or mildly reduced ejection fraction (55%) more often than in preserved ejection fraction (17%). Opinions diverge sharply on whether to pause or continue oral neurohormonal therapies during infusion. This survey shows that IVV are used in a limited number of patients with AHF and practice is highly heterogeneous across centers. These findings underscore the need for prospective trials to clarify which subsets derive hemodynamic or prognostic benefit.