In congestive cardiac failure all are used except -

Trimetazidine "Trimetazidine is .a novel antianginal agent that is used mostly as an add on medication to conventional therapy in angina and post M.I. patients". K.D.T. 6th/e p. 535-36 Nesiritide It is a recombinant ,form of human brain natriuretic peptide that has been approved by the FDA for treatment of dyspnoea due to congestive hea .failure. The natriuretic peptides, atrial natriuretic peptide (ANP), brain natriuretic peptide and C type natriuretic peptide are a family of endogenous neurohormones that posess natriuretic, diuretic and vasodilator propeies. They are secreted in response to stretch of ventricular myocytes. Nesiritide lowers right and left side cardiac filling pressures without a direct chronotropic or inotropic action. - The hemodynamic response to nesiritide is characterized by decreased right atrial, pulmonary aerial and pulmonary capillary wedge pressure. - Systemic vascular resistance is reduced and cardiac index is increased. - There is improvement in global clinical status, attenuation of dyspnoea and fatigue and enhanced diuretic responsiveness have been repoed and corroborated. In acute hea failure the two primary hemodynamic determinants that produce symptoms are ? a) Elevated left ventricular, filling pressure b) Depressed cardiac output. - The depressed cardiac output is frequently accompanied by increase in systemic vascular resistance as a result of excessive neurohormonal activation. Management of acute hea failure The drugs used in acute hea failure mainly acts to improve these two hemodynamic parameters.