Inotropes in acute heart failure

Acute heart failure (AHF) encompasses a wide range of clinical presentations, from acute hypertensive heart failure (HF) to low cardiac output hypoperfusion syndromes with cardiogenic shock at the extreme end of this side. Inotropes are pharmacologic agents that enhance cardiac contractility, thereby augmenting cardiac output. Currently, there are three classes of inotropes available in clinical practice with distinct mechanisms of action: beta-adrenergic agonists, phosphodiesterase III inhibitors, and the calcium-sensitizer levosimendan. Inotropes are indicated as short-term therapy in low cardiac output AHF and cardiogenic shock (usually with coadministration of a vasoconstrictor) to increase cardiac output, restore peripheral perfusion, and prevent end-organ dysfunction. Inotropes can cause serious cardiovascular adverse effects, most commonly tachyarrhythmias and myocardial ischemia and are associated with increased medium- and long-term mortality in HF. Therefore, intense monitoring is necessary during their administration, while long-term infusion is contraindicated with the exception of advanced HF patients in whom inotropes may be used as a bridge to a definitive therapy (transplantation or ventricular assist device implantation) or as palliative treatment. Emerging inotropes acting through novel pathways independent of those targeted by conventional agents may overcome safety limitations of currently available agents.

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