From the Guidelines
Milrinone is indicated for the short-term treatment of acute decompensated heart failure and for patients with advanced heart failure who are awaiting heart transplantation. It works as a phosphodiesterase-3 inhibitor that increases cardiac contractility (positive inotropic effect) and causes vasodilation (reducing afterload and preload) 1. The typical dosing regimen includes a loading dose of 50 mcg/kg administered intravenously over 10 minutes, followed by a continuous infusion of 0.375-0.75 mcg/kg/minute 1.
Key Considerations
- Milrinone is particularly useful in patients with reduced cardiac output, pulmonary congestion, and elevated pulmonary capillary wedge pressure.
- It can also be beneficial in patients with right ventricular dysfunction or pulmonary hypertension.
- Patients receiving milrinone require close monitoring for hypotension, arrhythmias, and electrolyte imbalances, particularly potassium.
- Renal dose adjustment is necessary as milrinone is primarily eliminated by the kidneys.
- Unlike traditional inotropes like dobutamine, milrinone does not act through beta-adrenergic receptors, making it valuable in patients who are on beta-blockers or have downregulated beta receptors due to chronic heart failure 1.
Monitoring and Safety
- Monitor ECG and blood pressure when using inotropic agents and vasopressors, as they can cause arrhythmia, myocardial ischemia, and hypotension 1.
- Intra-arterial blood pressure measurement may be considered in certain cases.
- Thrombo-embolism prophylaxis is recommended in patients not already anticoagulated and with no contra-indication to anticoagulation 1.
Clinical Context
- The use of milrinone should be guided by the most recent and highest quality evidence, with consideration of the individual patient's clinical context and potential risks and benefits 1.
- The decision to use milrinone should prioritize morbidity, mortality, and quality of life as the primary outcomes.
From the FDA Drug Label
Milrinone Lactate Injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The main indication of milrinone is for the short-term intravenous treatment of patients with acute decompensated heart failure 2.
- The treatment should be done with close observation and appropriate equipment.
- It is commonly used in patients who are also receiving digoxin and diuretics.
From the Research
Milrinone Indication
- Milrinone is used in the treatment of end-stage heart failure patients who are refractory to optimal medical therapy 3.
- It can also be employed as a home infusion therapy or a bridge to cardiac transplant 3.
- Milrinone is indicated for the management of acute decompensated heart failure (ADHF) 4, 5, 6, 7.
- It is used in patients with ADHF who have low cardiac index and evidence of systemic hypoperfusion or congestion 4.
- Milrinone can be used in patients with cardiogenic shock due to acute decompensated heart failure 5.
- It is compared to dobutamine in the management of ADHF, with some studies showing improved mortality and hemodynamics with milrinone 5, 7.
Comparison with Dobutamine
- Milrinone and dobutamine are both used in the treatment of ADHF, but there is no clear consensus on which one is more effective 4, 6, 7.
- Some studies have shown that milrinone is associated with lower mortality and improved hemodynamics compared to dobutamine 5, 7.
- However, other studies have found no significant difference in outcomes between the two groups 4, 6.
- A meta-analysis comparing the efficacy of dobutamine versus milrinone in ADHF and cardiogenic shock found a marginal benefit of milrinone over dobutamine 7.
Clinical Use
- Milrinone is typically used in patients with severe heart failure who are refractory to other treatments 3.
- It is often used in conjunction with other medications, such as diuretics and vasodilators, to manage symptoms and improve cardiac function 3.
- The dosage of milrinone is typically adjusted based on the patient's response to treatment and their renal function 3.