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Acute heart failure is a disease with various etiologies that is difficult to treat and has a poor prognosis. If causal treatment--revascularization, treatment of a hypertensive crisis--is not possible, symptomatic treatment takes over, based primarily on intravenous treatment with diuretics, vasodilators and/or positive inotropes. Despite undoubted progress in this form of treatment, large, randomised clinical studies have never proved the success of this treatment or confirmed an improvement in prognosis. For this reason most recommendations are based only on clinical experience and surrogate targets such as a reduction in BNP or shortening of the hospitalisation period. Great attention is directed in particular to natriuretic peptides (nesiritide, ularitide) and to levosimendan, which is a calcium sensitizer with a vasodilatory and positive inotropic effect. Nevertheless, even this medicine has not yet been shown to reduce mortality in large studies.

In recent years some specialists recommend to treat patients with cardiovascular diseases with maximal doses of drugs and refer to the results of extensive clinical studies. On critical evaluation of some it seems that the results are not interpreted accurately and that the highest doses of drugs (or combined treatment) do not produce better results than the use of smaller doses. This applies e.g. to the study HOT with felodipine in hypertensive patients and patients with cardiac insufficiency in the ATLAS study with lisinopril and the MERIT-HF study with metoprolol. It applies also the HOPE study with ramipril in secondary prevention in subjects with cardiovascular diseases. Efforts to achieve as low as possible lipid values has also some pitfalls. The author recommends to treat comprehensively all patients and to select maximal doses only in selected subjects.