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

Abstract

Inotropes are pharmacological agents that are indicated for the treatment of patients presenting with acute heart failure (AHF) with concomitant hypoperfusion due to decreased cardiac output. They are usually administered for a short period during the initial management of AHF until haemodynamic stabilisation and restoration of peripheral perfusion occur. They can be used for longer periods to support patients as a bridge to a more definite treatment, such as transplant of left ventricular assist devices, or as part of a palliative care regimen. The currently available inotropic agents in clinical practice fall into three main categories: beta-agonists, phosphodiesterase III inhibitors and calcium sensitisers. However, due to the well-documented potential for adverse events and their association with increased long-term mortality, physicians should be aware of the indications and dosing strategies suitable for different types of patients. Novel inotropes that use alternative intracellular pathways are under investigation, in an effort to minimise the drawbacks that conventional inotropes exhibit.

Leading predictors of early and late hospital mortality among patients with acute decompensated heart failure and ways to improve prognosis

“…В настоящее время клиническая медицина не располагает универсальными инотропными и вазоактивными препаратами, которые оказались бы более эффективными в отношении улучшения прогноза пациента по сравнению с добутамином или норадреналином [8,9]. Имеются отдельные клинические исследования, свидетельствующие о том, что левосимендан в сравнении с добутамином может оказаться более эффективным в отношении влияния на маркеры почечной и печеночной дисфункции без значимого положительного влияния на конечные точки [7,10].…”

Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use

“…These observations may be usefully contextualised into a ‘right patient, right drug’ schema that can be used to guide vasoactive and/or inotropic therapy ( Table 3 ). [ 105 ] The first phase of this schema examines whether or not an inotrope is needed at all and includes exclusion of otherwise treatable causes or the availability of viable alternatives. The next step is to identify the most suitable inotrope; levosimendan figures prominently in several categories, including cardiogenic shock, cardiac surgery and right ventricular failure.…”

Structural Heart Disease Emergencies

“…Application of standard therapies for ADHF and shock may be ineffective or even harmful in certain SHD emergencies (Table 3). 16,17 Specifically, the increased heart rate (HR) or afterload resulting from inotropes or vasopressors can paradoxically worsen hemodynamics in specific SHD emergencies. The intra-aortic balloon pump (IABP) remains controversial for patients with CS due to AMI but is a standard part of management for selected SHD emergencies and contraindicated in others (Table 3); the same is true for other percutaneous MCS devices including extracorporeal membrane oxygenation (ECMO).…”