4 November 2019
November 2019 post
In a recent expert opinion paper by Farmakis et al., published on Int J Cardiol (doi: 10.1016/j.ijcard.2019.09.005; PMID: 31615650) the authors summarized the proceedings of a meeting organized by the Heart Failure Clinic, Attikon University Hospital, Athens, Greece on the topic “A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure”.
Experts from 21 countries (Austria, Belgium, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, Poland, Russia, Slovenia, Spain, Sweden, Switzerland, and Turkey) attended and reached a consensus
In a nutshell, inotropes increase cardiac output by enhancing cardiac contractility through different mechanisms of action, but they also bear variable vasodilatory or vasoconstrictive effects depending on agent and dosage. They constitute an important tool for the treatment of patients with acute heart failure (AHF) or advanced heart failure (AdHF), as they are often effective in improving hemodynamics and symptoms. However, their administration has been associated with increased short and long-term mortality due to frequent adverse effects, but also due to their improper use. The classes of inotropes currently used in HF are the β-adrenergic receptor agonists including dopamine, dobutamine and the catecholamines norepinephrine and epinephrine, the PDE III inhibitor milrinone and the calcium sensitizer levosimendan.
In AHF, inotropes are indicated with a IIb recommendation by the ESC guidelines only for patients with peripheral hypoperfusion because of low cardiac output. Identifying patients with truly low cardiac output in need of inotropic support can be challenging, while selecting the proper agent according to patients’ clinical profile and limiting infusion to the shortest time and lowest dose possible are important to optimize inotrope use. Levosimendan bears some advantages in this setting, especially for its beneficial effects in presence of beta-blockers, and its positive renal effects.
In AdHF, inotropic agents are required for the relief of persistent symptoms and the improvement of quality of life. Day clinic-based or home-based repetitive infusions may reduce hospital admission, which is a key factor in the quality of live and perhaps overall prognosis of the disease. Levosimendan bears an advantage in this setting due to its long-acting active metabolite.
The paper provides a practical approach to the three main steps required for the optimal use of inotropes in heart failure, namely (i) the identification of the right patient, (ii) the choice of the proper inotrope and (iii) the definition of the adequate weaning time.
The effects of inotropes on QoL in general, remain poorly defined, and more studies on this important and clinically meaningful aspect of AHF and AdHF patient care are warranted.