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Inotropic therapy for end-stage heart failure patients
Mustafa Toma1, Randall C Starling
1Department of Cardiovascular Medicine, Heart and Vascular Institute, Desk J3-4, Kaufman Center for Heart Failure, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
Current Treatment Options in Cardiovascular Medicine
|September 16, 2010
Summary
Positive inotropic agents offer acute benefits for heart failure (HF) but carry risks in chronic use. Current guidelines reserve them for acute decompensated HF, bridge to transplant, or palliative care in end-stage HF.
Area of Science:
- Cardiology
- Pharmacology
- Heart Failure Management
Background:
- Positive inotropic agents are crucial for acute decompensated heart failure (HF) with low cardiac output.
- Their role in chronic advanced HF is limited due to risks like arrhythmias and mortality.
- Existing oral inotropes have shown mixed results or increased mortality in trials.
Purpose of the Study:
- To review the role and limitations of positive inotropic agents in managing heart failure.
- To discuss the risks and benefits of various inotropic agents in different HF stages.
- To outline current guideline recommendations for inotropic agent use.
Main Methods:
- Review of existing literature on positive inotropic agents in heart failure.
- Analysis of clinical trial data, including PROMISE, ESSENTIAL, and PERSIST trials.
- Examination of current clinical practice guidelines from major cardiology societies.
Main Results:
- Intravenous beta-agonists and phosphodiesterase inhibitors improve symptoms but increase risks.
- Oral milrinone showed increased mortality; oral enoximone provided no significant benefit.
- Levosimendan shows promise in acute HF but not in chronic oral therapy; istaroxime is under investigation.
Conclusions:
- Inotropic agents are primarily indicated for acute decompensated HF, bridge to transplantation, or palliative care in end-stage HF.
- Use in chronic advanced HF is limited due to significant adverse event profiles.
- Digoxin remains an option for symptom improvement, while other inotropes require careful consideration and are reserved for specific scenarios.
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