Milrinone is an invaluable agent in the treatment of end-stage heart failure patients who are refractory to optimal medical therapy. In addition to its use in acute decompensated heart failure, milrinone can also be employed as a home infusion therapy or a bridge to cardiac transplant. Concerns about its adverse effects, such as an increased risk of arrhythmias and hypotension, often limit the doses of milrinone used in clinical practice. In addition, milrinone is infrequently used or avoided entirely in patients with acute renal failure or end-stage renal disease because the drug is primarily cleared by renal excretion. Despite these concerns, studies that comprehensively reconcile the dose-response relationship and adverse events are scarce, and no clear provisions exist to guide milrinone dosing. After a brief discussion of the pharmacokinetics of milrinone, this article examines milrinone dosing, observed hemodynamic benefits, and documented adverse events across different studies.
Pulmonary hypertension, which may lead to right ventricular (RV) failure, increases with left ventricular (LV) diastolic dysfunction severity. The prevalence and determinants of RV failure were analyzed in 120 patients admitted with acute left heart (LH) failure. Patients were divided into RV failure (n=50) and non-RV failure (n=70) groups. The prevalence of RV failure was found to be 42%. In both groups, two thirds of the patients had isolated LV diastolic dysfunction and the rest had combined LV systolic and diastolic dysfunction. Patients in the RV failure group were characterized by higher LV diastolic grade (2.2 ± 0.6 vs 1.84 ± 0.7; P=.0070), pulmonary artery systolic pressure (PASP; 57.8 ± 15.3 vs 50.14 ± 12.1 mm Hg; P=.0028), right atrial enlargement (92% vs 25.7%; P=.000001), and more-than-moderate tricuspid regurgitation (58% vs 27.1%; P=.0006). RV failure is a frequent finding in patients with advanced LH failure. It is strongly associated with the severity of LV diastolic dysfunction and the severity of PASP.
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