Do you administer inotropes for low Left Ventricular (LV) function?

From the Guidelines

Inotropes should not be given for low left ventricular (LV) function alone, but rather for cardiogenic shock or acute decompensated heart failure with evidence of hypoperfusion, as stated in the most recent guidelines 1.

Key Considerations

• Inotropes, such as dobutamine and milrinone, are used to manage hypoperfusion in acute heart failure, but their use is associated with increased mortality risk and should be reserved for short-term use in acute settings 1.
• The decision to use inotropes should be based on the presence of signs of hypoperfusion, such as cold, clammy skin, acidosis, renal impairment, or impaired mentation, rather than solely on low LV function 1.
• 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 (starting at 0.01-0.03 mcg/kg/min) or epinephrine (starting at 0.01-0.05 mcg/kg/min) may be preferred 1.

Important Points to Consider

• Inotropes increase myocardial oxygen demand and can cause arrhythmias, so their use should be cautious and monitored closely 1.
• Chronic inotrope therapy is not recommended for stable heart failure patients with low LVEF due to increased mortality risk 1.
• The target blood pressure to reach in cardiogenic shock patients is unknown and still debated, but the latest recommendations suggest an objective of 65 mmHg of mean blood pressure 1.

From the FDA Drug Label

Milrinone lactate is a positive inotrope and vasodilator, with little chronotropic activity different in structure and mode of action from either the digitalis glycosides or catecholamines Clinical studies in patients with congestive heart failure have shown that milrinone lactate produces dose-related and plasma drug concentration-related increases in the maximum rate of increase of left ventricular pressure 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

Inotropes can be given for low left ventricular (LV) function or depressed contractility, as indicated by the use of milrinone and dobutamine in patients with congestive heart failure or cardiac decompensation 2 3.

• Milrinone has been shown to produce increases in the maximum rate of increase of left ventricular pressure and improve diastolic function.
• Dobutamine is indicated for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility.

From the Research

Inotropes for Low Left Ventricular (LV) Function

• Inotropes can be used in patients with severe systolic heart failure, including those with low left ventricular ejection fraction (LVEF) and signs of end-organ dysfunction in the setting of low cardiac output 4.
• The use of inotropes in patients with low LVEF is associated with risks and adverse events, and their use should be carefully considered and monitored 4.
• In patients with acute decompensated heart failure, inotropes such as dobutamine and milrinone may be used to increase cardiac output and improve symptoms, but their use should be limited to patients with evidence of poor tissue perfusion 5.

Selection of Inotropes

• The choice of inotrope depends on the individual patient's characteristics, such as the presence of ischemia, degree of congestion, and renal function 5.
• Dobutamine and milrinone are commonly used inotropes in patients with low LVEF, with dobutamine increasing cardiac output and contractility more than milrinone in some studies 6.
• Milrinone may be preferable in patients with significant pulmonary venous hypertension 5.

Outcomes of Inotrope Therapy

• Inotrope therapy can improve symptoms and quality of life in patients with advanced heart failure, but may be associated with worse survival 7.
• Patients who receive inotropes for palliation or as a bridge to transplant or left ventricular assist device (LVAD) have a median survival of around 9 months, with actuarial 1-year survival of around 47% 7.
• Inotropes can be effective as a bridge to transplant or LVAD, with around 90% of patients successfully maintained on inotropes until transplant or LVAD 7.