Are inotropes (inotropic agents) useful in patients with normal ejection fraction (EF)?

From the Guidelines

Inotropes are not recommended for patients with normal ejection fraction (EF) unless they are hypotensive, hypoperfused, or shocked. The use of inotropes in patients with normal EF is generally not beneficial and may even be harmful, as it can lead to increased heart rate, arrhythmias, and myocardial ischemia 1. According to the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure, inotropic agents are not recommended unless the patient is hypotensive (systolic blood pressure <85 mmHg), hypoperfused, or shocked due to safety concerns 1.

Key Points to Consider

• Inotropes like dobutamine work by increasing cardiac contractility, which is beneficial in heart failure with reduced ejection fraction (HFrEF), but not in patients with normal EF 1.
• Patients with normal EF experiencing symptoms like shortness of breath or fatigue should be investigated for other causes, such as diastolic dysfunction, valvular disease, or non-cardiac conditions 1.
• Treatment should target the underlying cause rather than using inotropes, and if a patient with normal EF is experiencing hemodynamic compromise, addressing volume status, controlling heart rate, or treating other contributing factors would be more appropriate than inotropic therapy 1.
• The ESC guidelines recommend an i.v. infusion of an inotrope (e.g. dobutamine) only in patients with hypotension (systolic blood pressure <85 mmHg) and/or hypoperfusion to increase cardiac output, increase blood pressure, and improve peripheral perfusion 1.

Clinical Implications

• Clinicians should exercise caution when considering inotropic therapy in patients with normal EF, as the potential benefits are outweighed by the risks of adverse effects 1.
• Alternative treatments, such as addressing volume status, controlling heart rate, or treating other contributing factors, should be prioritized over inotropic therapy in patients with normal EF 1.

From the Research

Inotropes and Normal Ejection Fraction

• The provided studies do not directly address the use of inotropes in patients with normal ejection fraction (EF) 2, 3, 4, 5, 6.
• The studies focus on the use of inotropes in patients with heart failure, reduced ejection fraction, and circulatory shock, indicating that inotropes are typically used in patients with impaired cardiac function 2, 3, 4.
• There is no clear evidence to support the use of inotropes in patients with normal EF, as the studies do not provide information on this specific patient population 2, 3, 4, 5, 6.

Use of Inotropes in Heart Failure

• Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability or as a bridge to decision 2.
• Inotropes can also be used in patients with severe heart failure who are not candidates for advanced heart failure therapies, such as transplant and mechanical circulatory support, for palliative therapy 2.
• The use of inotropes in heart failure is associated with improved symptoms, but worse survival in clinical trials 4.

Inotrope Selection and Dosing

• The choice of inotrope drug and dosing strategy depends on various factors, including the patient's underlying condition, hemodynamic status, and clinical goals 3, 6.
• Dobutamine, milrinone, and levosimendan are commonly used inotropes, each with its own pharmacological properties and potential benefits and risks 3, 6.
• The dosing of inotropes should be individualized and titrated to achieve the desired clinical response while minimizing adverse effects 3, 6.