Inotropic therapy in patients with advanced heart failure. A clinical consensus statement from the Heart Failure Association of the European Society of Cardiology

Abstract

This clinical consensus statement reviews the use of inotropic support in patients with advanced heart failure. The current guidelines only support use of inotropes in the setting of acute decompensated heart failure with evidence of organ malperfusion or shock. However, inotropic support may be reasonable in other patients with advanced heart failure without acute severe decompensation. The clinical evidence supporting use of inotropes in these situations is reviewed. Particularly, patients with persistent congestion, systemic hypoperfusion, or advanced heart failure with need for palliation, and specific situations relevant to implantation of left ventricular assist devices or heart transplantation are discussed. Traditional and novel drugs with inotropic effects are discussed and use of guideline‐directed therapy during inotropic support is reviewed. Finally, home inotropic therapy is described, and palliative care and end‐of‐life aspects are reviewed in relation to management of ongoing inotropic support (including guidance for maintenance and weaning of chronic inotropic therapy support).

Worsening of chronic heart failure: definition, epidemiology, management and prevention. A clinical consensus statement by the Heart Failure Association of the European Society of Cardiology

“…Indeed, these patients spend a substantial amount of time in hospital (‘frequent flyers’). In these patients intermittent treatment with inotropic agents has been proposed while, also, considering them for advanced treatments 113,114 . Recurrent worsening episodes can be the preamble to lack of response to GRMT and, thus, trigger candidacy to heart transplantation, durable mechanical circulatory support and palliative care.…”

“…In these patients intermittent treatment with inotropic agents has been proposed while, also, considering them for advanced treatments. 113,114 Recurrent worsening episodes can be the preamble to lack of response to GRMT and, thus, trigger candidacy to heart transplantation, durable mechanical circulatory support and palliative care. Data from retrospective studies showed that ambulatory patients with advanced HF (INTERMACS profiles 4-7) might benefit from long-term mechanical circulatory support even more than those with cardiogenic shock (INTERMACS 1-2) or inotrope-dependent (INTERMACS 3) due to the lower risk of complications.…”

April 2023 at a glance: focus on diagnosis and comorbidities

“…Improving their treatment is a major unmet need 3 . In this issue of the Journal, the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) provides a consensus statement on the pharmacology, indications and unmet needs regarding inotropic agents in patients with advanced HF, focusing also on palliative care and end‐of‐life aspects 4 …”

Overcoming vulnerability in heart failure: Transitional tactical toughness

“…Another approach focuses on haemodynamic-directed therapy by using either vasodilators or inotropic therapy during this transitional care period. 7,8 Generally, such an approach employs frequent ambulatory administration of intravenous vasodilators or inotropic therapy, coupled with diuretic augmentation, to improve symptom burden, mitigate extracardiac organ failure and hopefully reduce health resource use. However, such an approach has generally been a failure irrespective of whether the intervention uses inotropic or vasodilatory circulatory support.…”

“…However, such an approach has generally been a failure irrespective of whether the intervention uses inotropic or vasodilatory circulatory support. 7,8 One haemodynamically-guided management strategy using information from an implantable wireless pulmonary artery pressure sensor to direct treatment changes has shown promise and success in reducing heart failure hospitalization, particularly among patients who are moderately symptomatic (New York Heart Association class III) and who have previously been hospitalized with heart failure. 9,10 The third approach is one of invasive Laplace therapies that uses structural mechanical interventions to address mechanical cardiac perturbations by correcting cardiac physio-anatomical abnormalities such as asynchronous contractility (via cardiac resynchronization therapy) Figure 1 A schematic depicting the causes for vulnerability and increased risk in the transitional period after discharge from a heart failure hospitalization.…”