What is the role of inotropes in acute decompensated heart failure?

From the Guidelines

Inotropes should be used with caution in patients with acute decompensated heart failure, only in those with evidence of low cardiac output, hypotension, and end-organ dysfunction despite adequate filling pressures, due to increased mortality risk with prolonged use. The use of inotropes in acute decompensated heart failure is a complex issue, and the decision to use them should be based on a thorough assessment of the patient's hemodynamic status and clinical symptoms. According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, inotropic agents such as dobutamine, dopamine, levosimendan, and phosphodiesterase III inhibitors may be considered in patients with hypotension (SBP <90 mmHg) and/or signs of poor peripheral perfusion to maintain end-organ function.

Some key points to consider when using inotropes in acute decompensated heart failure include:

• First-line inotropes include dobutamine (starting at 2-5 mcg/kg/min, titrated up to 20 mcg/kg/min) and milrinone (loading dose of 50 mcg/kg over 10 minutes, followed by 0.375-0.75 mcg/kg/min) 1
• For patients with hypotension, norepinephrine (0.01-0.3 mcg/kg/min) or epinephrine (0.01-0.1 mcg/kg/min) may be preferred 1
• Dopamine can be used at low doses (1-3 mcg/kg/min) for renal perfusion and higher doses (5-15 mcg/kg/min) for inotropic effects 1
• Duration of inotrope use should be as short as possible, typically days rather than weeks, with continuous hemodynamic monitoring and frequent reassessment 1
• Potential complications of inotrope use include arrhythmias, myocardial ischemia, and tachyphylaxis 1

It is essential to note that inotropes should be used as a bridge to recovery, mechanical circulatory support, or heart transplantation rather than as long-term therapy due to increased mortality risk with prolonged use 1. The 2016 ESC guidelines also recommend that inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused because of safety concerns 1.

In terms of specific recommendations, the 2016 ESC guidelines suggest that dobutamine and milrinone are the preferred inotropes for use in acute decompensated heart failure, with norepinephrine and epinephrine being considered in patients with hypotension 1. The guidelines also emphasize the importance of continuous hemodynamic monitoring and frequent reassessment of the patient's clinical status to minimize the risks associated with inotrope use.

Overall, the use of inotropes in acute decompensated heart failure requires careful consideration of the patient's individual clinical status and hemodynamic profile, as well as close monitoring and frequent reassessment to minimize the risks associated with their use.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures Milrinone Lactate Injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure

Inotrope use in acute decompensated heart failure is supported by the FDA drug labels for:

• Dobutamine (IV): for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility 2
• Milrinone (IV): for the short-term intravenous treatment of patients with acute decompensated heart failure 3 Key points:
• Both dobutamine and milrinone are indicated for short-term use only
• Long-term use of cyclic-AMP-dependent inotropes, such as dobutamine, has been associated with increased risk of hospitalization and death 2

From the Research

Inotrope Use in Acute Decompensated Heart Failure

• Inotropes are pharmacological agents used to treat patients with acute heart failure (AHF) and concomitant hypoperfusion due to decreased cardiac output 4.
• They are typically administered for a short period during the initial management of AHF until haemodynamic stabilisation and restoration of peripheral perfusion occur 4.
• Inotropes can be used for longer periods to support patients as a bridge to a more definite treatment, such as transplant of left ventricular assist devices, or as part of a palliative care regimen 4, 5.

Types of Inotropic Agents

• The currently available inotropic agents in clinical practice fall into three main categories: beta-agonists, phosphodiesterase III inhibitors, and calcium sensitisers 4, 6.
• Examples of inotropic agents include dobutamine, dopamine, milrinone, and levosimendan 7, 6.

Indications and Dosing Strategies

• Physicians should be aware of the indications and dosing strategies suitable for different types of patients, as inotropes have a potential for adverse events and are associated with increased long-term mortality 4.
• The use of inotropes is supported by current guidelines in the setting of acute decompensated heart failure with evidence of organ malperfusion or shock 8.
• Inotropic support may be reasonable in other patients with advanced heart failure without acute severe decompensation, such as those with persistent congestion, systemic hypoperfusion, or advanced heart failure with need for palliation 8.

Palliative Care and End-of-Life Aspects

• Home inotropic therapy is an option for patients with advanced heart failure, and palliative care and end-of-life aspects should be considered in relation to management of ongoing inotropic support 8, 5.
• Questions arise regarding care at the end of life, such as what criteria determine ongoing clinical benefit, and whether the inotrope should be continued until death 5.