Inotropes in acute heart failure

Abstract

Acute heart failure (AHF) encompasses a wide range of clinical presentations, from acute hypertensive heart failure (HF) to low cardiac output hypoperfusion syndromes with cardiogenic shock at the extreme end of this side. Inotropes are pharmacologic agents that enhance cardiac contractility, thereby augmenting cardiac output. Currently, there are three classes of inotropes available in clinical practice with distinct mechanisms of action: beta-adrenergic agonists, phosphodiesterase III inhibitors, and the calcium-sensitizer levosimendan. Inotropes are indicated as short-term therapy in low cardiac output AHF and cardiogenic shock (usually with coadministration of a vasoconstrictor) to increase cardiac output, restore peripheral perfusion, and prevent end-organ dysfunction. Inotropes can cause serious cardiovascular adverse effects, most commonly tachyarrhythmias and myocardial ischemia and are associated with increased medium-and long-term mortality in HF. Therefore, intense monitoring is necessary during their administration, while long-term infusion is contraindicated with the exception of advanced HF patients in whom inotropes may be used as a bridge to a definitive therapy (transplantation or ventricular assist device implantation) or as palliative treatment. Emerging inotropes acting through novel pathways independent of those targeted by conventional agents may overcome safety limitations of currently available agents.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/ 5608943/Activity.aspx

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus

“…Once inotropes are deemed necessary, the choice of the proper agent should be based on patient's profile as determined by medical history, background medications, hemodynamic status and comorbid conditions [31]. In patients with decompensated ischemic HF without true hypoperfusion, milrinone showed a deleterious effect [32], while levosimendan has been associated with a trend towards survival improvement in different meta-analyses [22].…”

“…Inotropic agents in current use for the treatment of heart failure (modified from Bistola V & Chioncel O[31]). …”

Inotropes in Acute Heart Failure: From Guidelines to Practical Use: Therapeutic Options and Clinical Practice

“…The most notable adverse effects of dopamine include hypertension and tachyarrhythmias that are more frequently encountered at doses of >10 μg/kg/min. [5]…”

“…They are most commonly used in hospital settings for patients with peripheral organ hypoperfusion and severely diminished cardiac output. [5] However, the use of inotropes does have some adverse effects, including arrhythmogenesis and myocardial ischaemia, contributing to an unfavourable impact on long-term survival. As a result, their use is not recommended as routine practice for all patients with HF.…”

Outcomes of the patients of heart failure with reduced ejection fraction receiving inotropic support in initial 6 hours: Insights from Manipal Heart Failure Registry

“…Clinical presentation of acute HF includes the new onset or sudden deterioration of signs and symptoms which extends from worsening dyspnea to pulmonary edema or acute critical stage of cardiogenic shock. Beta-adrenergic agonists, calcium-sensitizer, and phosphodiesterase III inhibitors are three classes of inotropes currently trending in practice with distinct mechanisms (Bistola and Chioncel, 2017). Dopamine and levosimendan are two important inotropes that show mixed mechanisms being used in acute decompensated HF (ADHF) or refractory HF for immediate relief from symptoms.…”