Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization

A review of the contemporary use of inotropes in patients with heart failure

PURPOSE OF REVIEW

The role of inotropes has evolved with its use now expanding over multiple indications including cardiogenic shock, low cardiac output states, bridging therapy to transplant or mechanical support, and palliative care. There remains no consensus as to the recommended inotrope for the failing heart. We aim to provide an overview of the recent literature related to inotrope therapy and its application in patients with advanced heart failure and hemodynamic compromise.

RECENT FINDINGS

In this review, we outline various clinical scenarios that warrant the use of inotrope therapy and the associated recommendations. There remains no mortality benefit with inotrope use. Per American Heart Association recommendations, the choice of the inotropic agent should be guided by parameters such as blood pressure, concurrent arrhythmias, and availability of the medication. Outcome variability remains a heightened concern with inpatient inotropic use in both hemodynamically stable and unstable patients. Finally, inotropic use in palliative care continues to be a recommendation for symptom control and improvement in functional status when the appropriate social support is present for the patient.

SUMMARY

In summary, the ideal inotropic agent remains at the discretion of the clinical provider. Different clinical scenarios may favor one agent over another based on the type of cardiogenic shock and mechanism of action of the inotrope. A future shift towards characterizing inotrope use based on subgroup cardiogenic shock profiles may be seen, however further studies are needed to better understand these phenotypes. Inotrope therapy remains a keystone to bridging to advanced therapies and palliative care.

Guide to Temporary Mechanical Support in Cardiogenic Shock: Choosing Wisely

Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized.

Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence

Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.

Long-Term Ambulatory Intravenous Milrinone Therapy in Advanced Heart Failure

BACKGROUND

The role of intravenous (IV) inotropes in the treatment of ambulatory patients with advanced heart failure (HF) remains controversial.

METHODS

This was a retrospective study of patients with advanced HF. Patients on home IV milrinone, who remained on it for at least 3 months, were included. We compared the data from 3 months before starting IV milrinone to 3 months after initiating therapy. A subset of patients who remained on milrinone for 6 months or longer was analysed separately.

RESULTS

A total of 90 patients remained on continuous IV milrinone for 3 months, and 55 patients were treated for 6 months or longer. In both groups, improvements in cardiac index (1.86-2.25, p<0.001 and 1.9-2.38, p<0.0001), New York Heart Association (NYHA) class (3.32-2.76, p<0.0001 and 3.25-2.72, p=0.001), and liver function were noted. In the 6-month group, there was also a decrease in mean hospitalised days per patient (9.40 vs 4.12, p<0.001) and an improved tolerance of beta blocker therapy (83.3% vs 98.1%, p=0.006).

CONCLUSION

Long-term IV use of milrinone is associated with improvement in haemodynamics, functional class, tolerance of medical therapy, and decrease in hospitalised days.