Clinical Use of Inotropic Therapy for Heart Failure: Looking Backward or Forward?

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Abstract
Therapy with intravenous inotropic agents is most often initiated as short-term therapy during hospitalization to achieve one of several goals for acute management of decompensation, as described in part I of this report (Table).1 However, it may become difficult to wean these infusions in some patients as a heart failure progresses to late stages. View this table: Current Uses of Inotropic Agents in Heart Failure: Possible Trials ### Identification of Inotrope Dependence Many considered initially to be dependent on inotropic infusions can undergo successful weaning after complete diuresis of excess volume and careful adjustment of concomitant oral medications, which may be facilitated by hemodynamic monitoring to optimize loading conditions on oral agents.2,3 β-Adrenergic receptor antagonists would have been discontinued already in most cases. ACE inhibitors may need to be discontinued to maximize blood pressure and renal function, with addition of nitrates with or without hydralazine as needed for vasodilation. Dependence should not be declared until multiple interventions and weaning attempts have been made, in most cases requiring 2 to 3 weeks in the hospital, a systematic approach discussed by Hershberger et al.3 Although its magnitude can be debated, there is clearly a population of patients who are considered by experienced heart failure teams to be dependent on intravenous inotropic infusions despite multiple weaning attempts.4 It is assumed that such patients would not survive hospital discharge without ongoing inotropic support, although consensus has not been reached on exactly who they are. Dependence is most often manifested as symptomatic hypotension, recurrent congestive symptoms, or worsening renal function early after discontinuation of inotropic therapy. It should be emphasized that dependence for clinical purposes should be defined by limited clinical function, not by measured hemodynamic parameters, although these numbers have been required for Medicare coverage of home infusions in some states. For patients considered dependent, continuous inotropic …