Repetitive Treatments With Inotropes in Advanced Heart Failure

Abstract

A dvanced heart failure (AdHF) is characterized by a progressive worsening of disabling symptoms, which are (or become) refractory to all therapies, and by a high rehospitalization rate and mortality (Fig. 1). These patients may be candidates for life-prolonging therapies, such as heart transplantation or long-term mechanical circulatory support, or must just require palliative therapies. 1 Inotropic therapy has been considered for the long-term treatment of such patients to preserve hemodynamic and symptomatic balance, to prevent their frequent rehospitalization, and to support their overall quality of life (QoL). 2 After all, AdHF represents the extreme end of the spectrum of heart failure and has the worst prognosis. 3 In this context, I read with interest the article by Zhang X et al 4 "Comparative effectiveness and safety of intermittent or repeated use of levosimendan, milrinone, or dobutamine in patients with advanced heart failure: a network meta-analysis" published in this issue of J Cardiovasc Pharmacol. I commend the authors for their contribution in a field characterized by the absence of large clinical studies: Meta-analyses of the existing evidence can ignite the spark for further research.Zhang et al focus on the safety and efficacy of intermittent or repeated infusion or oral use of levosimendan, milrinone, and dobutamine in patients with AdHF. These patients often have difficulty tolerating guideline-directed pharmacologic therapy for heart failure and may require inotropic therapy to maintain a reasonable QoL.The authors compared levosimendan, milrinone, dobutamine, and respective control groups for intermittent or prolonged therapy in patients with AdHF with different outcomes by a network and single-arm meta-analysis of relevant clinical data extracted from the literature in a systematic review.Levosimendan was found to be the only 1 of the 3 selected inotropes that did not significantly increase mortality compared with the control treatments and was more effective in improving brain natriuretic peptide levels and left ventricular ejection fraction (LVEF). Conversely, more hypotension events were observed in the levosimendan group. In a nutshell, the results suggest that compared with milrinone and dobutamine, the intermittent use of levosimendan with close monitoring of blood pressure is relatively safe in patients with AdHF and is associated with better prognosis.The authors of this valuable work acknowledge that exercise has some important limitations that merit enumeration here.