Dobutamine as bridge to angiotensin-converting enzyme inhibitor-nitrate therapy in endstage heart failure

The Role of Positive Inotropic Drugs in the Treatment of Older Adults with Heart Failure and Reduced Ejection Fraction

Positive inotropic drugs have long been studied for their potential benefits in patients with heart failure and reduced ejection fraction (HFrEF). Although there has been an extensive amount of research about the clinical effects of these drugs in general, few studies examined their effect in older patients. Therefore, there is little or no evidence to guide the use of positive inotropes in older patients with HFrEF. However, recommendations from national heart failure guidelines may be generalized to older HFrEF patients on an individual basis, taking into consideration the basic geriatric principles of pharmacotherapy: start low and go slow.

From acute decompensated to chronic heart failure

An acute decompensation of heart failure resulting in hospital admission represents a critical juncture in the natural history of the disease, as evidenced by poor mortality and readmission outcomes after hospital discharge. For this reason, a number of new short-term vasoactive therapies have been or are being tested in clinical trials. Furthermore, in response to unacceptable readmission rates, there has been intense interest in improving the transition from hospital discharge to the outpatient arena. Between these 2 areas of focus exists an often overlooked internal transition from acute vasoactive therapies to oral chronic heart failure medications. This transition from acute presentation to the rest of the hospital stay forms the basis of this review.

Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly

Heart failure (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.

Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly

HF (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.

Intravenous vasodilator therapy in congestive heart failure

The prevalence of congestive heart failure (CHF) is increasing in the US and worldwide, partly because patients are living longer. Treatment of CHF is mostly on an outpatient basis, but inpatient care is required for decompensated CHF, acute CHF or poor response to outpatient treatment. Control of symptoms is usually achieved by diuresis. Intravenous (IV) vasodilators are an important adjunct to the inpatient treatment of CHF. They work mainly by reducing the afterload on the myocardium although preload reduction also occurs. After clinical stabilisation, the goal is to switch to a maintenance oral regimen to be continued as outpatient therapy. The range of IV vasodilators available for inpatient treatment of CHF includes nitrates, phosphodiesterase inhibitors, dobutamine, morphine, ACE inhibitors, B-type natriuretic peptides and endothelin receptor antagonists. As each agent may have a different mechanism or site of action, each agent may affect preload, contractility or afterload to a different extent and it may be desirable to choose one over the other in a particular clinical setting. Examples of standard therapy include dobutamine, milrinone and nitroglycerin. Nesiritide, a B-type natriuretic peptide, is a newer vasodilator and US FDA approved for use in acute CHF. However, most studies with this agent have been in small numbers of patients with anecdotal findings. Larger studies are warranted to pinpoint the efficacy and adverse effects of this agent. It is primarily used to reduce the acuity of decompensated CHF on admission to hospital.Endothelin receptor antagonists show promise in the management of acute CHF, but continue to be investigational. Long-term data on their efficacy and safety are limited. None of the endothelin receptor antagonists are FDA approved for use in patients with CHF.