Abstract
The most common use of inotropes is among hospitalized patients with acute decompensated heart failure, with reduced left ventricular ejection fraction and with signs of end-organ dysfunction in the setting of a low cardiac output. Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability or as a bridge to decision. In cases where patients are unable to be weaned off inotropes, these agents can be used until a definite or escalated supportive therapy is planned, which can include coronary revascularization or mechanical circulatory support (intra-aortic balloon pump, extracorporeal membrane oxygenation, impella, left ventricular assist device, etc.). Use of inotropic drugs is associated with risks and adverse events. This review will discuss the use of the inotropes digoxin, dopamine, dobutamine, norepinephrine, milrinone, levosimendan, and omecamtiv mecarbil. Long-term inotropic therapy should be offered in selected patients. A detailed conversation with the patient and family shall be held, including a discussion on the risks and benefits of use of inotropes. Chronic heart failure patients awaiting heart transplants are candidates for intravenous inotropic support until the donor heart becomes available. This helps to maintain hemodynamic stability and keep the fluid status and pulmonary pressures optimized prior to the surgery. On the other hand, in patients with severe heart failure who are not candidates for advanced heart failure therapies, such as transplant and mechanical circulatory support, inotropic agents can be used for palliative therapy. Inotropes can help reduce frequency of hospitalizations and improve symptoms in these patients.
Highlights
Inotropic agents have been in use for many years for the treatment of patients with acute decompensated systolic heart failure, known as heart failure with reduced left ventricular ejection fraction (HFrEF)
Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability, or as a bridge to decision
One of these studies showed that women with a left ventricular ejection fraction (LVEF) less than 35%, and a serum digoxin concentration between 0.5 and 1.1 ng/mL, did not have increased mortality and had reduced hospitalization for heart failure symptoms
Summary
Inotropic agents have been in use for many years for the treatment of patients with acute decompensated systolic heart failure, known as heart failure with reduced left ventricular ejection fraction (HFrEF). These drugs improve the contractility of the myocardium by definition, but can affect the heart rate and peripheral vascular resistance. Due to advancements in advanced heart failure therapies, including transplant and mechanical circulatory support, their use is becoming more common for other indications. In cases where patients are unable to be weaned off inotropes, these agents can be used until a definite or escalated supportive therapy is planned, which can include coronary revascularization or mechanical circulatory support (intra-aortic balloon pump, extracorporeal membrane oxygenation, impella, left ventricular assist device, etc.).
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