Short-term intravenous milrinone for severe congestive heart failure: the good, bad, and not so good

We evaluated the overall hemodynamic and clinical effects, beneficial and deleterious, of short-term intravenous milrinone in the management of severe congestive heart failure (CHF). Numerous hemodynamic measurements were obtained in 24 patients (mean age 65 yrs) with advanced, severe CHF (New York Heart Association class IV, ejection fraction 24 +/- 5%), including 3 with concomitant clinical sepsis. Hemodynamic data were recorded at baseline and after a bolus of intravenous milrinone 50 micrograms/kg and maintenance infusion based on creatinine clearance at 0.5, 3, 24 and 48 hours. Cardiac index increased and pulmonary capillary wedge pressure decreased significantly (p < 0.001; 2.07 +/- 0.36 to L/min/m2 and 20.6 +/- 4.0 to 13.5 +/- 2.8 mm Hg, respectively) in 24 patients 0.5 hour after initiation of therapy. These favorable hemodynamic responses, including significant decreases in systemic vascular resistance index and right atrial pressure, were sustained throughout the 48-hour study in 19 patients (79%). Severe hypotension occurred in three patients with superimposed sepsis as the result of exaggerated vasodilatation. One patient had recurrent ventricular tachycardia and another tolerance to milrinone. In two patients, excessive decline in preload and fall in cardiac index were reversed with volume expansion. Intravenous milrinone offered significant short-term hemodynamic benefits in most patients with severe CHF.