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Earl GL, Verbos-Kazanas MA, Fitzpatrick JM, Narula J. Tolerability of beta-blockers in outpatients with refractory heart failure who were receiving continuous milrinone. Pharmacotherapy 2007; 27:697-706. [PMID: 17461705 DOI: 10.1592/phco.27.5.697] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To investigate the dosing, tolerability, and outcomes associated with the use of concomitant beta-blockers and inotropic therapy in patients with refractory heart failure during the first 6 months of their therapy. DESIGN Retrospective review. SETTING University-based, tertiary care heart failure and transplant center. PATIENTS Sixteen inotrope-dependent outpatients with end-stage refractory heart failure who were receiving continuous intravenous milrinone. Of these patients, 12 also received an oral beta-blocker; the remaining four patients who did not receive beta-blockers served as the comparator group. MEASUREMENTS AND MAIN RESULTS For each patient, the initial and final study drug doses of continuous intravenous milrinone and oral beta-blocker treatment, when applicable, were recorded over the 6-month period. Mean heart rate, blood pressure, ejection fraction, and oxygen consumption were measured, and 95% confidence intervals were calculated. Serum sodium and creatinine concentrations, as well as the creatinine clearance, were measured. In the 12 patients who received concomitant milrinone and beta-blockers, the mean baseline ejection fraction was approximately 18%, and they received milrinone for 18.6 weeks. Seven patients received carvedilol for 16.1 weeks, and five received metoprolol tartrate for 17.6 weeks. Dosages of the beta-blockers were titrated. Final daily doses were carvedilol 42.8 mg (95% confidence interval 20.3-65.4) and metoprolol 42.5 mg (95% confidence interval 28.0-57.2). Patients continued to receive other standard oral drug therapy for heart failure. One patient discontinued metoprolol and one discontinued carvedilol because of hypotension and/or worsening heart failure. Cardiac adverse events in the concomitant milrinone plus beta-blocker group were heart failure requiring hospitalization in 10 patients and ventricular arrhythmias in one. CONCLUSION Inotrope-dependent patients with refractory end-stage heart failure tolerated continuous intravenous milrinone plus beta-blockers in addition to diuretics and vasodilators for the 6-month observation period. Beta-blocker dosages were titrated, and three patients achieved the target beta-blocker dosage established for stage A-C heart failure. Additional studies are needed to determine the optimal selection and dosing of drug combinations in this population.
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Simkova V, Radermacher P, Barth E. Metabolic effects of phosphodiesterase III inhibitors: another reason to promote their use? Crit Care 2007; 11:139. [PMID: 17572916 PMCID: PMC2206415 DOI: 10.1186/cc5924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Phosphodiesterase III inhibitors combine positive inotropic and vasodilator properties. These inhibitors are therefore frequently used to treat low cardiac output and/or severe left heart failure associated with cardiac surgery. Their effects on energy metabolism and visceral organ function are not well studied, however, particularly in comparison with their 'competitors' in daily practice (that is, catecholamines).
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Schofield RS, Pierce GL, Nichols WW, Klodell CT, Aranda JM, Pauly DF, Hill JA, Braith RW. Arterial-wave reflections are increased in heart failure patients with a left-ventricular assist device. Am J Hypertens 2007; 20:622-8. [PMID: 17531918 DOI: 10.1016/j.amjhyper.2006.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 11/12/2006] [Accepted: 12/24/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Chronic heart failure (HF) is associated with increased central arterial pulse-wave reflections, which may contribute to increased myocardial oxygen demand. Although the treatment of HF via left-ventricular assist device (LVAD) placement has recently become widespread, the effects of LVAD therapy on central arterial pulse-wave reflections are unknown. METHODS Central aortic pulse-wave analysis was performed on patients with end-stage HF awaiting cardiac transplantation and on healthy age-matched controls using the SphygmoCor (Akor Medical, Sydney, Australia) system. Arterial pulse-wave data were compared between patients receiving LVAD support versus those receiving intravenous inotropic drugs and healthy control patients. RESULTS Five patients on LVAD support were compared with 10 patients on inotropic drugs and 10 healthy control patients. Aortic augmented pressure and the aortic augmentation index (AI(a)) were higher in LVAD patients compared with inotrope and control patients, despite similar brachial and aortic blood pressures between groups. The AI(a) was significantly higher in LVAD patients than in patients on inotropic drugs (28.2% +/- 10% v 7.9% +/- 9%, P < or = .01). Additionally, there was a significantly higher aortic systolic tension time index, an index of left-ventricular myocardial oxygen demand, in the LVAD group compared with the inotrope group (2655 +/- 298 mm Hg/sec/min v 1748 +/- 303 mm Hg/sec/min, P < .01). CONCLUSIONS Central arterial pressure-wave reflection is increased in end-stage HF patients on LVAD support compared with those on inotropic drugs, leading to an increase in aortic augmented pressure, AI(a), and systolic tension time index. The AI(a) is also higher in LVAD patients than in healthy controls. This increased central arterial-wave reflection places an additional hemodynamic load on the LVAD device and may have relevance to the medical management of patients after LVAD placement and to the longevity of the LVAD device itself.
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Watanabe H, Kajimoto K, Kawana M. [Combination therapy with PDE III inhibitor for heart failure]. NIHON RINSHO. JAPANESE JOURNAL OF CLINICAL MEDICINE 2007; 65 Suppl 5:134-9. [PMID: 17571377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Abstract
Acute heat failure syndromes are a heterogenous group of conditions. Chronic heart failure exacerbations represent the vast majority of cases. Pathophysiologic mechanisms, such as hypotension with peripheral tissue hypoperfusion, renal function impairment and myocardial ischemia and injury, adversely affect patients' clinical outcome. Classical inotropes, such as beta-agonists (dobutamine, dopamine) and phosphodiesterase inhibitors (milrinone), seem to improve clinical symptoms and hemodynamics of acutely decompensated chronic heat failure patients, but they have been associated with increased long-term mortality. Thus, on the basis of the available evidence, these agents can be used only as a temporary treatment of acute heart failure exacerbations with stringent criteria (ESC AHF guidelines), resistant to intravenous vasodilators and/or diuretics when systolic blood pressure (SBP) is >100 mmHg or as a first-line treatment in patients with worsening of chronic cardiac failure and low SBP (<100 mmHg). The calcium sensitizer levosimendan is a new cardiac enhancer that seems to be more effective than classical inotropes in improving cardiac mechanical efficiency and reducing congestion, without causing cardiomyocyte death or increasing myocardial oxygen uptake. Recent randomized trials showed that levosimendan is not superior to placebo or dobutamine in improving 1- and 6-month mortality, although it caused a greater reduction of neurohormonal response. More data are needed regarding patient selection and the optimum regimen and dosing of levosimendan before this treatment modality become the first line therapy of acutely decompensated chronic heart failure patients.
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Barraud D, Faivre V, Damy T, Welschbillig S, Gayat E, Heymes C, Payen D, Shah AM, Mebazaa A. Levosimendan restores both systolic and diastolic cardiac performance in lipopolysaccharide-treated rabbits: Comparison with dobutamine and milrinone. Crit Care Med 2007; 35:1376-82. [PMID: 17414729 DOI: 10.1097/01.ccm.0000261889.18102.84] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Current treatment strategies for severe septic conditions (i.e., intravenous fluids, vasopressors, and cardiac inotropes) reestablish fluid balance and improve cardiac systole but do not address diastolic dysfunction. Our study aimed to fully characterize both systolic and diastolic abnormalities of sepsis-associated heart failure and to identify treatment that would support full-cycle cardiac improvement. DESIGN Endotoxin-injected rabbits, an animal model of abnormal cardiac function in human sepsis, were used to delineate cardiac abnormalities and to examine effects of drug treatments on heart systolic and diastolic function (n = 30); saline-injected animals served as comparators (n = 17). As treatment, three inotropes commonly used for treatment of cardiac failure were infused for 45 mins in separate animal groups-milrinone, dobutamine, and levosimendan. MEASUREMENTS Variables of left ventricular systolic and diastolic function were assessed with a pressure conductance catheter. Measurements were made before and after endotoxin/saline injection and before and after inotrope treatment. RESULTS Pressure-volume analyses of the left ventricle showed marked impairment in systolic function and in all indices of diastolic function (isovolumic relaxation time constant, left ventricular end-diastolic pressure, and end-diastolic pressure-volume relationship) in endotoxin-treated rabbits. The inotropes, milrinone, dobutamine, and levosimendan, could each partially or completely restore systolic function in the lipopolysaccharide-treated rabbits. However, only levosimendan therapy led to additional beneficial effects on left ventricular relaxation and diastolic function. CONCLUSIONS Cardiac failure in severe sepsis results from impairments in both systolic and diastolic functions. Treatment with the calcium sensitizer levosimendan improved both systolic and diastolic cardiac functions in septic animals, but cyclic adenosine monophosphate-dependent inotropes milrinone and dobutamine only improved systolic function.
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Berg AM, Snell L, Mahle WT. Home Inotropic Therapy in Children. J Heart Lung Transplant 2007; 26:453-7. [PMID: 17449413 DOI: 10.1016/j.healun.2007.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Revised: 01/30/2007] [Accepted: 02/03/2007] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Inotropic therapy is a well-established practice for children with advanced congestive heart failure (CHF). Traditionally, children have been maintained on inotropic therapy in the hospital under close, monitored supervision. Changes to UNOS listing criteria now allow patients awaiting heart transplantation to be discharged to home yet maintain 1B status. In adults, home inotropic therapy has been shown to be a safe and cost-effective bridge to transplantation. To date, there are limited data on the use of home inotropic therapy in children. METHODS We reviewed the safety and efficacy of continuous ambulatory home inotropic therapy in children. Data were obtained from a single institution from January 2000 to January 2007. RESULTS There were 14 pediatric patients with end-stage CHF, who received home intravenous inotropic therapy. The indications for home inotropic therapy included palliative care (n = 8) and awaiting heart transplantation (n = 6). Patients ranged in age from 6 to 18 years (median 14.5 years). The majority of subjects (n = 11) received milrinone at a dose of 0.5 to 1.0 mug/kg/min, 2 received dobutamine at 5 mug/kg/min, and 1 received both agents. Duration of therapy ranged from 14 to 476 days (median 68 days). There were 26 hospital re-admissions and 4 suspected catheter infections. No unexpected deaths or pump failures occurred. CONCLUSIONS Based on this initial review, continuous home inotropic therapy in children with CHF is safe with few complications. Home inotropic therapy may result in substantial cost-savings and improve family dynamics by avoiding prolonged hospitalization.
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Pagel PS. Levosimendan in Cardiac Surgery: A Unique Drug for the Treatment of Perioperative Left Ventricular Dysfunction or Just Another Inodilator Searching for a Clinical Application? Anesth Analg 2007; 104:759-61. [PMID: 17377077 DOI: 10.1213/01.ane.0000256864.75206.6d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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De Hert SG, Lorsomradee S, Cromheecke S, Van der Linden PJ. The Effects of Levosimendan in Cardiac Surgery Patients with Poor Left Ventricular Function. Anesth Analg 2007; 104:766-73. [PMID: 17377079 DOI: 10.1213/01.ane.0000256863.92050.d3] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with poor left ventricular function often require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan improves cardiac function by a novel mechanism of action compared to currently available drugs. We hypothesized that, in patients with severely compromised ventricular function, the use of levosimendan would be associated with better postoperative cardiac function than with inotropic drugs that increase myocardial oxygen consumption. METHODS Thirty patients with a preoperative ejection fraction < or =30% scheduled for elective cardiac surgery with cardiopulmonary bypass were randomized to two different inotropic protocols: milrinone 0.5 microg [corrected] x kg(-1) x min(-1) or levosimendan 0.1 microg [corrected] x kg(-1) x min(-1), started immediately after the release of the aortic crossclamp. The treatment was masked to the observers. All patients received dobutamine 5 microg [corrected] x kg(-1) x min(-1). RESULTS Stroke volume was similar between groups initially after surgery, but it declined 12 h after surgery in the milrinone group but not in the levosimendan group (P < 0.05 between groups) despite similar filling pressures. Total dose, duration of inotropic drug administration and norepinephrine dose were lower in the levosimendan group than in the milrinone group (P < 0.05). The duration of tracheal intubation was shorter in the former group compared with the milrinone group (P = 0008). Three patients in the milrinone group but none in the levosimendan group died within 30 days of surgery. CONCLUSION In cardiac surgery patients with a low preoperative ejection fraction, stroke volume was better maintained with the combination of dobutamine with levosimendan than with the combination of dobutamine with milrinone.
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Abstract
Pharmacologic agents including vasodilators, inotropes, and vasopressors are frequently used in the critical care setting for management of the unstable cardiac patient. These medications are used to elicit varying effects on vascular resistance, myocardial contractility, and heart rate to help achieve desired hemodynamic and clinical endpoints. Therefore, it is important for the critical care nurse to have a practical understanding and working knowledge of cardiovascular pharmacotherapy in the intensive care unit setting. This article reviews the pharmacology and clinical utility of commonly used intravenous "vasoactive" medications encountered in the intensive care unit. We also highlight innovations in pharmacotherapy for this patient population, and provide practical considerations for the most appropriate and safe use of these medications.
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Saltzman HE, Sharma K, Mather PJ, Rubin S, Adams S, Whellan DJ. Renal dysfunction in heart failure patients: what is the evidence? Heart Fail Rev 2007; 12:37-47. [PMID: 17393304 DOI: 10.1007/s10741-007-9006-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Accepted: 02/13/2007] [Indexed: 01/13/2023]
Abstract
Congestive heart failure (CHF) is an increasingly common medical condition and the fastest growing cardiovascular diagnosis in North America. Over one-third of patients with heart failure also have renal insufficiency. It has been shown that renal insufficiency confers worsened outcomes to patients with heart failure. However, a majority of the larger and therapy-defining heart failure medication and device trials exclude patients with advanced renal dysfunction. These studies also infrequently perform subgroup analyses based on the degree of renal dysfunction. The lack of information on heart failure patients who have renal insufficiency likely contributes to their being prescribed mortality and morbidity reducing medications and receiving diagnostic and therapeutic procedures at lower rates than heart failure patients with normal renal function. Inclusion of patients with renal insufficiency in heart failure studies and published guidelines for medication, device, and interventional therapies would likely improve patient outcomes.
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Han XZ, Sun Y. [Intravenous milrinone in the treatment of pediatric heart failure]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2007; 9:73-4. [PMID: 17306085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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Stocker CF, Shekerdemian LS, Nørgaard MA, Brizard CP, Mynard JP, Horton SB, Penny DJ. Mechanisms of a reduced cardiac output and the effects of milrinone and levosimendan in a model of infant cardiopulmonary bypass. Crit Care Med 2007; 35:252-9. [PMID: 17133188 DOI: 10.1097/01.ccm.0000251123.70632.4e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A low cardiac output state is an important cause of morbidity after pediatric cardiopulmonary bypass. The objectives of our study were to define the early precipitants of the reduced cardiac output and to investigate the effects on these of milrinone and levosimendan in a model of pediatric cardiopulmonary bypass. DESIGN Experimental study. SETTING : Research laboratory at a university-affiliated, tertiary pediatric center. SUBJECTS Eighteen piglets. INTERVENTIONS Piglets, instrumented with systemic, pulmonary arterial, and coronary sinus catheters, pulmonary and circumflex arterial flow probes, and a left ventricular conductance-micromanometer-tipped catheter, underwent cardiopulmonary bypass with aortic cross-clamp and cardioplegic arrest. At 120 mins, they were assigned to control, milrinone, or levosimendan groups and studied for a further 120 mins. MEASUREMENTS AND MAIN RESULTS In controls, between 120 and 240 mins, cardiac output decreased by 15%. Systemic vascular resistance was unchanged, but pulmonary vascular resistance increased by 19%. Systemic arterial elastance increased by 17%, indicating increased afterload. End-systolic elastance was unchanged, and coronary sinus oxygen tension decreased by 4.0 +/- 1.7 mm Hg. In animals receiving milrinone cardiac output was preserved, and in animals receiving levosimendan cardiac output increased by 14%. Both drugs prevented an increase in arterial elastance and pulmonary vascular resistance after cardiopulmonary bypass. Systemic vascular resistance decreased by 31% after levosimendan, and end-systolic elastance increased by 48%, indicating improved contractility. Both agents prevented a decrease in coronary sinus oxygen tension. CONCLUSIONS Increased afterload, which is not matched by an equivalent elevation in contractility, contributes to the reduced cardiac output early after pediatric cardiopulmonary bypass in this model. This increase is prevented by milrinone and levosimendan. Both agents exert additional beneficial effects on pulmonary vascular resistance and myocardial oxygen balance, although levosimendan has greater inotropic properties.
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Heywood JT, Khan TA. The use of vasoactive therapy for acute decompensated heart failure: hemodynamic and renal considerations. Rev Cardiovasc Med 2007; 8 Suppl 5:S22-S29. [PMID: 18192950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Although diuretics remain the most commonly used intravenous medication for acute decompensated heart failure, vasoactive agents play an important role in select patient populations. Inotropes and pressor agents are critical in order to maintain blood pressure and cardiac output in a small subset of patients, and can preserve and even improve renal function. However, they should not be used in the majority of patients with preserved cardiac output. Vasodilators improve hemodynamics and symptoms in normotensive individuals. Their influence on renal function is less clear cut, although more recent data suggest a neutral effect.
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Hill JA, Hsu K, Pauly DF, Schofield R, Aranda JM. Sustained use of nesiritide to aid in bridging to heart transplant. Clin Cardiol 2006; 26:211-4. [PMID: 12769247 PMCID: PMC6653953 DOI: 10.1002/clc.4960260503] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Patients with end-stage heart failure awaiting heart transplant are often maintained on continuous intravenous inotropic therapy. However, this therapy alone is often inadequate for maintenance of appropriate pulmonary artery pressure and stable clinical course. Nesiritide, B-type natriuretic peptide, is a recently released intravenous vasodilator for short-term use in patients with decompensated heart failure. This report details experience in four patients in whom this agent was used to bridge to transplant for prolonged periods (11-35 days) with added clinical benefit and without obvious tolerance. This suggests that new strategies for pretransplant management may be needed.
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Hauptman PJ, Woods D, Prirzker MR. Novel use of a short-acting intravenous beta blocker in combination with inotropic therapy as a bridge to chronic oral beta blockade in patients with advanced heart failure. Clin Cardiol 2006; 25:247-9. [PMID: 12018885 PMCID: PMC6654261 DOI: 10.1002/clc.4950250512] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The role for beta blockers in advanced heart failure (New York Heart Association class IV) remains undefined because of concerns about tolerability and uncertainty about efficacy. We report the use of a short-acting intravenous beta blocker in combination with inotropic therapy as a means to bridge five patients with advanced heart failure to chronic oral beta blockade; two of these patients had been chronically managed with intravenous inotrope. At 4 months' follow-up, all patients remained on beta-blocker therapy and none was hospitalized for heart failure or had received intravenous diuretics. Given the early separation of survival curves in the randomized clinical trials of beta blockers in heart failure, it is possible that these patients will accrue a survival benefit. We conclude that some patients with advanced heart failure can be offered oral beta-blocker therapy by bridging with a combination of intravenous inotrope and short-acting intravenous beta blocker.
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Echols MR, Felker GM, Thomas KL, Pieper KS, Garg J, Cuffe MS, Gheorghiade M, Califf RM, O'Connor CM. Racial Differences in the Characteristics of Patients Admitted for Acute Decompensated Heart Failure and Their Relation to Outcomes: Results From the OPTIME-CHF Trial. J Card Fail 2006; 12:684-8. [PMID: 17174228 DOI: 10.1016/j.cardfail.2006.08.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 08/01/2006] [Accepted: 08/01/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data suggest that differences in response to therapy and survival exist between African Americans and Caucasians with heart failure. Whether these differences exist in acute decompensated heart failure (ADHF) is uncertain. METHODS AND RESULTS We analyzed data from the OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) study, a randomized trial of intravenous milrinone versus placebo in 949 patients hospitalized with ADHF. We evaluated differences in clinical characteristics, outcomes, and response to milrinone therapy in African American patients compared with Caucasians. The primary end point of OPTIME-CHF was days hospitalized for cardiovascular causes or death within 60 days of randomization. Thirty-three percent (n = 310) of patients were African American. African American patients were younger (57 vs. 70 years, P < .0001) and more likely to have non-ischemic cardiomyopathy (74% vs. 36%, P < .0001). In unadjusted analysis, African American patients had a lower 60-day mortality (5% vs. 12%, P = .0004) and tended to have better overall clinical outcomes. After adjustment for baseline differences, however, these differences were no longer significant. We found no differential effect of milrinone therapy by race. CONCLUSION African American patients with acute decompensated heart failure present with a different clinical profile than Caucasian patients. Although unadjusted clinical outcomes are better for African Americans presenting with ADHF, these differences diminished after adjustment for baseline characteristics.
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Sidi A, Muehlschlegel JD, Kirby DS, Lobato EB. Treatment of ischaemic left ventricular dysfunction with milrinone or dobutamine administered during coronary artery stenosis in the presence of beta blockade in pigs †. Br J Anaesth 2006; 97:799-807. [PMID: 17035336 DOI: 10.1093/bja/ael276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study examines the effects of phosphodiesterase type III (PDEIII) inhibition vs beta stimulation on global function of the left ventricle (LV) and systemic haemodynamics in a porcine model of acute coronary stenosis with beta blockade. METHODS A total of 18 adult swine were anaesthetized. Micromanometer-tipped catheters were placed in the ascending aorta and LV. Two pairs of ultrasonic dimension transducers were placed in the subendocardium on the short axis proximal to a left anterior descending (LAD) artery occluder and the long axis of the LV. Before ischaemia, i.v. esmolol was infused to decrease baseline heart rate (HR) by approximately 25%, and all animals received an esmolol infusion (150 microg kg(-1) min(-1)). Ischaemia was produced by reducing the flow in the LAD artery by approximately 80%, from 17(4) to 3(2) ml min(-1). Animals were randomized to receive (after esmolol) one of the following: no drug, sham only (Group 1, n=6), control (C); 50 microg kg(-1) i.v. milrinone (Group 2, n=6) followed by 0.375 microg kg(-1) min(-1) (M); or incremental doses of dobutamine (Group 3, n=6) every 10 min (5, 10 and 20 microg kg(-1) min(-1)) (D). Left ventricular function data obtained included HR, arterial and LV pressures, cardiac output (CO), Emax and dP/dT. Measurements were taken during five time periods: before ischaemia (at baseline, after esmolol) and every 10 min during ischaemia (at 10, 20 and 30 min). RESULTS The effects of beta blockade and ischaemia had a significant impact on contractility (Emax) in Group M and myocardial performance (left ventricular end-diastolic pressure, LVEDP) in all groups. Left ventricular function (Emax, CO, LVEDP and SVR) was better preserved when milrinone was added in Group M. A moderate dose of dobutamine (10 microg kg(-1) min(-1)) increased CO. Only the high dose (20 microg kg(-1) min(-1)) improved contractility (Emax), but at the expense of increased SVR. Also, LVEDP with either dose of dobutamine remained high and unchanged. CONCLUSIONS From our limited findings, it would appear that there may, theoretically, be some benefit for using milrinone in preference to other inotropic drugs in the presence of beta blockade. Milrinone administration should be considered in patients with acute ischaemic LV dysfunction and preexisting beta blockade before using other inotropic drugs such as beta stimulants.
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Hauptman PJ, Mikolajczak P, George A, Mohr CJ, Hoover R, Swindle J, Schnitzler MA. Chronic inotropic therapy in end-stage heart failure. Am Heart J 2006; 152:1096.e1-8. [PMID: 17161059 PMCID: PMC2840644 DOI: 10.1016/j.ahj.2006.08.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 08/08/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Interventions in advanced heart failure that provide symptom relief and decrease hospital readmission are important. Chronic intravenous inotropic therapy represents a pharmacologic approach that has been advocated for palliative treatment. However, little is known about associated mortality and cost. Therefore, we sought to describe the impact of chronic infusions on resource use and survival. METHODS Data were reviewed for a 17-state Medicare region from 1995 to 2002. We obtained hospital and outpatient expenditures accrued up to 180 days before and after the initiation of chronic infusions. Health care use was defined by dollars reimbursed for drug and hospitalizations per beneficiary. Average accumulated cost curves were generated for dollars reimbursed for drug and for hospitalizations by days at risk. RESULTS The mean age of the cohort (n = 331) was 69.1 +/- 11.3 years. Mortality exceeded 40% at 6 months. Reductions in hospital days were observed at all time points. The amounts reimbursed at 30 and 60 days before and after initiation of inotrope favor drug therapy; however, at six months, the amounts reimbursed were greater due to the cost of milrinone. CONCLUSIONS Chronic intravenous inotrope use was associated with a high mortality. The cost for milrinone was significant, but there was a decrease in expenditures for subsequent hospitalizations. In the absence of appropriately designed clinical trials, the data suggest that the decision to use inotropes, the choice of inotrope, and the duration of treatment should reflect the impact on resource use.
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McNamara PJ, Laique F, Muang-In S, Whyte HE. Milrinone improves oxygenation in neonates with severe persistent pulmonary hypertension of the newborn. J Crit Care 2006; 21:217-22. [PMID: 16769471 DOI: 10.1016/j.jcrc.2006.01.001] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Many neonates with severe persistent pulmonary hypertension of the newborn (PPHN) are nonresponders to inhaled nitric oxide (iNO). Milrinone is a promising adjunctive therapy because of its pulmonary vasodilator properties and cardiotropic effects. DESIGN Case series of neonates with severe PPHN (defined as oxygenation index [OI] >20, failure of iNO therapy, and echocardiographic confirmation of PPHN). SETTING Tertiary neonatal intensive care unit. SUBJECTS Full-term (> or =37 weeks) neonates with severe PPHN who received intravenous milrinone. MEASUREMENTS The primary end point was the effect of intravenous milrinone on OI and hemodynamic stability over a 72-hour study period. Secondary end points examined included duration of iNO and degree of cardiorespiratory support. RESULTS Nine neonates at a mean gestation of 39.25 +/- 2.76 weeks, birth weight of 3668 +/- 649.1 g, and baseline OI of 28.1 +/- 5.9 received milrinone treatment after a poor initial response to iNO treatment. Intravenous milrinone was commenced at a median age of 21 hours (range, 18-49 hours), and patients were treated for median of 70 hours (range, 23-136). Oxygenation index was significantly reduced after milrinone treatment, particularly in the immediate 24 hours of treatment (8.0 +/- 6.6, P < .001). There was a significant improvement in heart rate (179 +/- 15.2 vs 149.6 +/- 22.4, P < .001) over the same period. Infants who received milrinone did not develop systemic hypotension; in fact, there was a nonsignificant trend toward improved blood pressure. CONCLUSIONS Intravenous milrinone produces early improvements in oxygenation without compromising systemic blood pressure.
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Cripe LH, Barber BJ, Spicer RL, Wong BL, Weidner N, Benson DW, Markham LW. Outpatient continuous inotrope infusion as an adjunct to heart failure therapy in Duchenne muscular dystrophy. Neuromuscul Disord 2006; 16:745-8. [PMID: 17005398 DOI: 10.1016/j.nmd.2006.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Revised: 07/20/2006] [Accepted: 07/28/2006] [Indexed: 11/25/2022]
Abstract
We report the use of continuous intravenous inotrope infusion as a palliative management strategy for the treatment of symptomatic, refractory, end stage cardiac dysfunction in patients with Duchenne muscular dystrophy. Milrinone and/or dobutamine administered by continuous intravenous infusion provided symptomatic and objective cardiovascular improvement up to 30 months in 3 individuals with Duchenne muscular dystrophy and severe dilated cardiomyopathy. Continuous inotrope infusion should be considered a practical treatment strategy for end stage cardiac dysfunction in Duchenne muscular dystrophy patients when cardiac transplantation is not a viable option.
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97
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98
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Tanwiphongtrakun T, Inoue S, Furuya H. Proper use of phosphodiesterase inhibitors according to the situations. ACTA ANAESTHESIOLOGICA TAIWANICA : OFFICIAL JOURNAL OF THE TAIWAN SOCIETY OF ANESTHESIOLOGISTS 2006; 44:183-5. [PMID: 17037008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
We came across a case who because of sustained hypotension with normal cardiac output was given amrinone which offered an initial excellent response but showed impotency later and its replacement by milrinone dramatically improved the hemodynamic status. The ensuing hypotension was thought to be the consequence of the use of amrinone which was given to treat hypotension in conjunction with fluid therapy; besides, it also induced pulmonary hypertension. Therefore, milrinone was given to replace amrinone and was successfully to turn the tide. It is our suggestion that if the use of a phosphodiesterase (PDE) inhibitor is indicated but its side effects are enhanced to refute its use, the application of a different PDE inhibitor should be kept in mind.
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Lange M, Van Aken H, Westphal M. Is vasopressin really superior to norepinephrine in reversing milrinone-induced vasodilation? Eur J Cardiothorac Surg 2006; 30:689. [PMID: 16939712 DOI: 10.1016/j.ejcts.2006.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 05/16/2006] [Accepted: 07/19/2006] [Indexed: 10/24/2022] Open
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100
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Price JF, Towbin JA, Dreyer WJ, Moffett BS, Kertesz NJ, Clunie SK, Denfield SW. Outpatient continuous parenteral inotropic therapy as bridge to transplantation in children with advanced heart failure. J Card Fail 2006; 12:139-43. [PMID: 16520263 DOI: 10.1016/j.cardfail.2005.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2005] [Revised: 10/28/2005] [Accepted: 11/01/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Advanced heart failure in children is associated with high morbidity and mortality and is often refractory to standard medical therapy. The purpose of this study was to review our institutional experience with the use of outpatient parenteral inotropic therapy (PIT) for advanced chronic heart failure in children. METHODS AND RESULTS We reviewed the medical records of all patients treated with PIT as outpatients. Seven patients received outpatient PIT from 2/99 to 1/05 (mean age was 14.6 years +/- 3.7). Median duration of therapy was 10 weeks (range 4-84 weeks). The mean number of emergency department visits per patient was greater before starting PIT than after starting PIT (2.3 +/- 1.8 versus 1.1 +/- 2.2, P < .05). The mean number of hospital admissions from exacerbation of heart failure symptoms decreased after starting PIT (2.1 +/- 1.3 versus 0.6 +/- 0.8, P < .05). Mean EF% in patients with systolic dysfunction improved while on therapy (30 +/- 14% before versus 39 +/- 16% after, P < .05). There was 1 death and 5 complications in 2 patients. Six patients were successfully bridged to transplantation. CONCLUSION Outpatient continuous parenteral inotropic therapy may serve as a successful bridge to cardiac transplantation in selected pediatric outpatients.
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