The current and future status of inotropes in heart failure management

ABSTRACT

Introduction

Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient’s decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion.

Areas covered

Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF.

Expert opinion

The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.

KEYWORDS:

• Heart failure
• acute heart failure
• cardiogenic shock
• advanced heart failure
• inotropes
• vasopressors

Article highlights

• Heart failure is a complex syndrome with a wide range of presentations and varying levels of acuity, which require individualized therapeutic approach.

• Inotropes are agents that are widely used in the management of patients with acute heart failure, cardiogenic shock and advanced heart failure.

• Inotropes improve cardiac contractility, augment cardiac output, and restore peripheral and end-organ perfusion, yet at the expense of increased myocardial ischemia and arrhythmias, thus leading to worsening mortality outcomes.

• There is an imperative need for future studies to further investigate and possibly expand the indications of currently existing inotropes, and also to provide data regarding the safety and efficacy of novel agents.

Declaration of interest

John Parissis has received honoraria from Orion Pharma (Finland). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This article was not funded.