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McPherson A, Nguyen C, Groninger H, Anderson KM, Henderson P, Rao A. Continuous Intravenous Inotropic Support for Advanced Heart Failure: Palliative Considerations. J Pain Palliat Care Pharmacother 2022; 36:59-67. [PMID: 35319327 DOI: 10.1080/15360288.2022.2050456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.
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Abstract
Patients with advanced heart failure suffer from severe and persistent symptoms, often not responding disease-modifying drugs, a marked limitation of functional capacity and poor quality of life that can ameliorate with inotropic drugs therapy. In small studies, pulsed infusions of classical inotropes (ie, dobutamine and milrinone) are associated with improvement in hemodynamic parameters and quality of life in patients with advanced heart failure. However, because of the adverse effects of these drugs, serious safety issues have been raised. Levosimendan is a calcium-sensitizing inodilators with a triple mechanism of action, whose infusion results in hemodynamic, neurohormonal, and inflammatory cytokine improvements in patients with chronic advanced HF. In addition, levosimendan has important pleiotropic effects, including protection of myocardial, renal, and liver cells from ischemia-reperfusion injury, and anti-inflammatory and antioxidant effects; these properties possibly make levosimendan an "organ protective" inodilator. In clinical trials and real-world evidence, infusion of levosimendan at fixed intervals is safe and effective in patients with advanced HF, alleviating clinical symptoms, reducing hospitalizations, and improving the quality of life. Therefore, the use of repeated doses of levosimendan could represent the therapy of choice as a bridge to transplant/left ventricular assist device implantation or as palliative therapy in patients with advanced heart failure.
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Nandkeolyar S, Ryu R, Mohammad A, Cordero-Caban K, Abramov D, Tran H, Hauschild C, Stoletniy L, Hilliard A, Sakr A. A Review of Inotropes and Inopressors for Effective Utilization in Patients With Acute Decompensated Heart Failure. J Cardiovasc Pharmacol 2021; 78:336-345. [PMID: 34117179 DOI: 10.1097/fjc.0000000000001078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Inotropes and inopressors are often first-line treatment in patients with cardiogenic shock. We summarize the pharmacology, indications, and contraindications of dobutamine, milrinone, dopamine, norepinephrine, epinephrine, and levosimendan. We also review the data on the use of these medications for acute decompensated heart failure and cardiogenic shock in this article.
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Affiliation(s)
- Shuktika Nandkeolyar
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | - Adeba Mohammad
- Medicine, Loma Linda University Medical Center, Loma Linda CA
| | | | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | | | - Liset Stoletniy
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Anthony Hilliard
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Antoine Sakr
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
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Abstract
Heart failure is a complex clinical syndrome and represents the final path of numerous heart diseases. Coronary artery disease is recognized as the primary risk factor for heart failure development, being the main etiological factor in more than 50% of heart failure patients in North America and Europe. Regardless of overt coronary artery disease, myocardial ischemia is a common finding in failing hearts, likely due to structural or functional coronary circulation alterations. Ischemia is a self-propagating process which irreversibly impairs the cardiac function and negatively impacts prognosis. Thus, a better and thorough understanding of myocardial ischemia pathophysiology in heart failure would likely lead to significantly improved outcomes in these patients. This review aims to describe the mechanisms of myocardial ischemia and coronary artery disease in heart failure, focusing on coronary circulation dysfunctions due to increased parietal stress or non-obstructive coronary disease, and discussing the association and management of coronary artery disease in patients with heart failure.
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Affiliation(s)
- Beniamino R Pagliaro
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Francesco Cannata
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Giulio G Stefanini
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.
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Snipelisky D, Fudim M, Perez A, Nayor M, Lever NM, Raymer DS, Rosenbaum AN, AbouEzzeddine O, Hernandez AF, Stevenson LW, Gilstrap LG. Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2020; 4:529-536. [PMID: 33083701 PMCID: PMC7557209 DOI: 10.1016/j.mayocpiqo.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective To describe the intent and early outcomes of elective inotrope use during heart failure hospitalization. Patients and Methods A prospective multisite design was used to collect data for hemodynamically stable patients started electively on inotrope therapy between January 1 and August 31, 2018. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed up for events through hospital discharge and an additional survey was administered at the end of hospitalization. Results For the 92 patients enrolled, average age was 60 years and ejection fraction was 24%±12%. At the time of inotrope initiation, attending heart failure cardiologists predicted that 50% (n=46) of the patients had a “high or very high” likelihood of becoming dependent on intravenous inotropic therapy and 58% (n=53) had a “high” likelihood of death, transplant, or durable ventricular assist device placement within the next 6 months. Provider predictions regarding death/hospice or need for continued home infusions were accurate only 51% (47 of 92) of the time. Only half the patients (n=47) had goals-of-care conversations before inotrope treatment initiation. Conclusion More than half the patients (51 of 92) electively started on inotrope treatment without present or imminent cardiogenic shock ultimately required home inotrope therapy, died during admission, or were discharged with hospice. Heart failure clinicians could not reliably identify those patients at the time of inotrope therapy initiation and goals-of-care discussions were not frequently performed.
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Schnaubelt S, Breyer MK, Siller-Matula J, Domanovits H. Atrial fibrillation: a risk factor for unfavourable outcome in COVID-19? A case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 33089045 PMCID: PMC7337643 DOI: 10.1093/ehjcr/ytaa166] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/21/2020] [Accepted: 05/19/2020] [Indexed: 12/31/2022]
Abstract
Background Fulminant cardiac involvement in COVID-19 patients has been reported; the underlying suspected mechanisms include myocarditis, arrhythmia, and cardiac tamponade. In parallel, atrial fibrillation is common in the elderly population which is at particularly high risk for COVID-19 morbidity and mortality. Case summary A 72-year-old male SARS-CoV2-positive patient was admitted to the intensive care unit due to delirium and acute respiratory failure. Atrial fibrillation known from history was exacerbated, and made complex rate and rhythm control necessary. Progressive heart failure with haemodynamic deterioration and acute kidney injury with the need for continuous renal replacement therapy were further aggravated by pericardial tamponade. Discussion Treatment of acute heart failure in COVID-19 patients with a cytokine storm complicated by tachycardic atrial fibrillation should include adequate rate or rhythm control, and potentially immunomodulation.
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Affiliation(s)
| | | | - Jolanta Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Abstract
This article reviews treatment and management of common cardiovascular emergencies in critically ill patients, focusing on acute decompensated heart failure, cardiogenic shock, pulmonary embolism, and hypertensive crisis management with inotropes, vasopressors, diuretics, and antiarrhythmic drugs. Clinicians frequently come across challenging clinical scenarios, and there is a gap between evidence-based medicine and clinical practice. Inotropic and vasopressor agents are useful in the acute setting but must be weaned off or used as a bridge for mechanical circulation support devices. Clinicians should aim to lower complications by choosing medications with respect to comorbidities and close the gap between evidence-based medicine and clinical practice.
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Affiliation(s)
- Yogamaya Mantha
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Rakushumimarika Harada
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Michinari Hieda
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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Tune JD, Baker HE, Berwick Z, Moberly SP, Casalini ED, Noblet JN, Zhen E, Kowala MC, Christe ME, Goodwill AG. Distinct hemodynamic responses to (pyr)apelin-13 in large animal models. Am J Physiol Heart Circ Physiol 2020; 318:H747-H755. [PMID: 32108522 DOI: 10.1152/ajpheart.00365.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This study tested the hypothesis that (pyr)apelin-13 dose-dependently augments myocardial contractility and coronary blood flow, irrespective of changes in systemic hemodynamics. Acute effects of intravenous (pyr)apelin-13 administration (10 to 1,000 nM) on blood pressure, heart rate, left ventricular pressure and volume, and coronary parameters were measured in dogs and pigs. Administration of (pyr)apelin-13 did not influence blood pressure (P = 0.59), dP/dtmax (P = 0.26), or dP/dtmin (P = 0.85) in dogs. However, heart rate dose-dependently increased > 70% (P < 0.01), which was accompanied by a significant increase in coronary blood flow (P < 0.05) and reductions in left ventricular end-diastolic volume and stroke volume (P < 0.001). In contrast, (pyr)apelin-13 did not significantly affect hemodynamics, coronary blood flow, or indexes of contractile function in pigs. Furthermore, swine studies found no effect of intracoronary (pyr)apelin-13 administration on coronary blood flow (P = 0.83) or vasorelaxation in isolated, endothelium-intact (P = 0.89) or denuded (P = 0.38) coronary artery rings. Examination of all data across (pyr)apelin-13 concentrations revealed an exponential increase in cardiac output as peripheral resistance decreased across pigs and dogs (P < 0.001; R2 = 0.78). Assessment of the Frank-Starling relationship demonstrated a significant linear relationship between left ventricular end-diastolic volume and stroke volume across species (P < 0.001; R2 = 0.70). Taken together, these findings demonstrate that (pyr)apelin-13 does not directly influence myocardial contractility or coronary blood flow in either dogs or pigs.NEW & NOTEWORTHY Our findings provide much needed insight regarding the pharmacological cardiac and coronary effects of (pyr)apelin-13 in larger animal preparations. In particular, data highlight distinct hemodynamic responses of apelin across species, which are independent of any direct effect on myocardial contractility or perfusion.
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Affiliation(s)
- Johnathan D Tune
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hana E Baker
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Diabetes and Complications Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Zachary Berwick
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven P Moberly
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eli D Casalini
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jillian N Noblet
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eugene Zhen
- Diabetes and Complications Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Mark C Kowala
- Diabetes and Complications Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Michael E Christe
- Diabetes and Complications Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Adam G Goodwill
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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Iacovoni A, D'Elia E, Gori M, Oliva F, Lorini FL, Senni M. Treating Patients Following Hospitalisation for Acute Decompensated Heart Failure: An Insight into Reducing Early Rehospitalisations. Card Fail Rev 2019; 5:78-82. [PMID: 31179016 PMCID: PMC6545980 DOI: 10.15420/cfr.2018.46.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/19/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a pandemic syndrome characterised by raised morbidity and mortality. An acute HF event requiring hospitalisation is associated with a poor prognosis, in both the short and the long term. Moreover, early rehospitalisation after discharge negatively affects HF management and survival rates. Cardiovascular and non-cardiovascular conditions combine to increase rates of HF hospital readmission at 30 days. A tailored approach for HF pharmacotherapy while the patient is in hospital and immediately after discharge could be useful in reducing early adverse events that cause rehospitalisation and, consequently, prevent worsening HF and readmission during the vulnerable phase after discharge.
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Affiliation(s)
- Attilio Iacovoni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Emilia D'Elia
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Mauro Gori
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Fabrizio Oliva
- Cardiovascular Department, ASST Grande Ospedale Metropolitano Niguarda Milan, Italy
| | | | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
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