From the Research
Inotropes are generally not recommended for patients with ATTR-CM (transthyretin amyloid cardiomyopathy) due to their potential to cause harm and worsen outcomes. Traditional positive inotropic agents like dobutamine, milrinone, and digoxin should be avoided in ATTR-CM patients as they can increase myocardial oxygen demand and arrhythmia risk, which is particularly dangerous in hearts already compromised by amyloid deposits 1. Patients with ATTR-CM often have increased sensitivity to these agents, resulting in higher risks of hypotension and arrhythmias.
Instead, management should focus on:
- Volume control with careful diuretic use, maintaining euvolemia
- Specific ATTR-CM treatments like tafamidis, which stabilizes transthyretin and slows disease progression 2
- For patients with advanced disease requiring hemodynamic support, temporary mechanical circulatory support might be considered in specialized centers, but this should be viewed as a bridge to more definitive therapy or transplantation rather than a long-term solution
The fundamental issue is that inotropes cannot overcome the mechanical disadvantage created by amyloid infiltration and may worsen outcomes by increasing cardiac workload in an already stiffened heart. Tafamidis, the only agent approved by FDA for ATTR-CM, shows promise to improve survival and quality of life in patients with ATTR-CM 3.
Key considerations in managing ATTR-CM include: