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Advanced Therapeutic Options in Acute Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Tiffany Dong, Aditi Nayak, Alanna Morris
Inotropes (Table 9.2) improve hemodynamics and include dobutamine, milrinone, and dopamine. Despite favorable effects on cardiac output and filling pressures, inotropes are associated with ischemia from higher myocardial consumption, arrhythmias, and higher mortality—though these patients tend to be very ill.18 The OPTIME-CHF trial demonstrated higher in-hospital and 60-day mortality in patients with ADHF on milrinone compared to placebo. This group had increased incidence of atrial arrhythmias and hypotension, requiring intervention.19 This association with mortality is noted in the guidelines, as long-term continuous or intermittent use of IV inotropes for reasons other than palliation is harmful. Inotropes are indicated as a temporizing measure in cardiogenic shock or as a bridge to MCS or transplant.3 Thus, inotropes should be utilized judiciously in patients with systolic dysfunction and low cardiac index with evidence of hypoperfusion and should be discontinued when clinically indicated.
Cardiovascular Drugs during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
Cardiac glycosides cause inotropic effects on the heart and antiarrhythmic effects. Various digitalis preparations cross the placenta readily, resulting in fetal levels 50–80 percent of maternal levels (Chan et al., 1978; Rogers et al., 1972).
The Langendorff Heart
Published in John H. McNeill, Measurement of Cardiac Function, 2020
Considering that ventricular muscle is highly vascularized, inotropic agents perfused into the heart rapidly gain access to all ventricular muscle cells, leading to a greater sensitivity of the preparation to perfused agents. Hence, the Langendorff heart preparation is ideal for studying the concentrationdependent effects of positive and negative inotropic agents on cardiac contractility.2 Agents that increase the force of ventricular muscle contraction (positive inotropic agents) increase intraventricular pressure and the contractility index +dP/dtmax, while agents that reduce the force of contraction (negative inotropic agents) reduce intraventricular pressure and +dP/dtmax. An example of the effect of such agents on the guinea pig heart is shown in Figure 1.3 Additionally, as some inotropic agents alter heart rate and coronary flow, the Langendorff heart preparation described here eliminates limitations induced by these factors. For example, as negative inotropic agents reduce ventricular function, aortic perfusion pressure is diminished, leading to cessation of coronary flow and heart failure due to ischemia. In the Langendorff heart, coronary perfusion pressure and coronary flow are independent of ventricular muscle function. This is in contrast to the working heart model, where aortic perfusion pressure is dependent on left ventricular function.4 Finally, a fixed balloon size in the present preparation ensures measurement of isometric tension at an optimal muscle fiber length.
An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety
Published in Expert Review of Cardiovascular Therapy, 2021
Matthias Heringlake, Julian Alvarez, Dominique Bettex, Stefaan Bouchez, Sonja Fruhwald, Massimo Girardis, Elena Grossini, Fabio Guarracino, Antoine Herpain, Wolfgang Toller, Luigi Tritapepe, Piero Pollesello
Inotropic therapy has a long-established, although not always clearly defined, place in the treatment of heart failure. In the case of acute heart failure (AHF), whether arising de novo as a consequence of a myocardial infarction or as a decompensation of chronic congestive HF, intravenous (i.v.) adrenergic agents have been used for decades and may be regarded as the benchmark for agents of this sort. Experience with these agents has been problematic, however, with extensive reports of adverse events such as the development of cardiac arrhythmias and renal dysfunction [1] and little, if any, reliable indication that these interventions are associated with improved survival. In fact, substantial evidence points toward an increase in mortality when dobutamine is used in AHF [2] or when epinephrine is used in patients with cardiogenic shock (CS) [3]. Even norepinephrine, which is currently preferred to epinephrine in CS or AHF, was not associated with a survival benefit in a large collection of data [4,5].
Effect of levosimendan combined with recombinant human brain natriuretic peptide on diuretic resistance
Published in Libyan Journal of Medicine, 2021
Shen Xiangli, Li Lan, Zu Libiya, Ma Jun, Jiang Shubin
Heart failure (HF) is a progressive disorder with an estimated prevalence of 64.3 million people worldwide[1]. An important pathophysiologic process of HF is volume overload, which is conventionally treated with diuretics. However, their prolonged use can lead to diuretic resistance, which affects approximately 20% to 30% of patients with HF, increasing short- and long-term mortalities [2–5]. Inotropic drugs improve cardiac output by enhancing cardiac contractility, and has been considered as an attractive approach to provide improvements in HF symptoms [6]. Compared with other inotropes, levosimendan promotes sensitization of cardiomyocyte to calcium ions without increasing intracellular calcium levels, which may prevent an increased risk of cardiac arrythmia [7]. Levosimendan also acts as a vasodilator by regulating ATP-dependent potassium channels. By acting via both inotropic and vasodilatory approaches, the drug enhances cardiac output without increasing myocardial oxygen demand [8]. In most of the reported studies, the application of levosimendan on refractory HF has been mainly focused on the treatment of diuretic resistance [9,10]. However, despite advances in HF therapy, many patients do not respond to a levosimendan as a monotherapy and experience clinical deterioration [11]. To accelerate and improve its effects to lower diuretic resistance, levosimendan can be used in combination with other diuretic agents such as natriuretic peptides.
Current pharmacotherapeutic strategies for cardiac arrhythmias in heart failure
Published in Expert Opinion on Pharmacotherapy, 2020
Ashish Correa, Yogita Rochlani, Wilbert S. Aronow
Cardiac arrhythmias are frequently seen in patients with HF. These rhythm disturbances can be related to the underlying pathology that causes the HF (such as atrial myopathy, ischemic cardiomyopathy, and scar related arrhythmia). Conversely, the arrhythmia itself can precipitate HF, such as with tachycardia-mediated cardiomyopathy. Regardless of the etiology, arrhythmias often lead to worsening of HF and are the leading cause of death in this patient population. It is important to treat these arrhythmias to control symptoms, slow disease progression and prevent sudden death. Management depends on the type of arrhythmia (atrial or ventricular), the stage of HF and other comorbidities. Antiarrhythmic agents are often used along with device therapy and catheter ablation. However, antiarrhythmic agents come with their own problems, such as proarrhythmic and negative inotropic effects. The knowledge of cardiac arrhythmias seen in HF patients and their evidence-based pharmacologic management strategies are important for physicians caring for these patients.