Role of Inotropic Agents in the Treatment of Heart Failure

Systolic heart failure (HF) is a systemic disease caused by reduced cardiac contractility. Although it would seem logical that this disease could be treated with strategies to directly improve contractility, inotropic therapies in the HF population have universally failed to live up to their expectations. Paradoxically, favorable outcomes can be achieved by administering drugs that may transiently reduce contractility while blocking neurohormonal stimulation. The proven success of this latter approach, especially in combination with implantable cardioverter-defibrillator and cardiac resynchronization therapy, has drawn our attention away from addressing the root cause of the problem: reduced contractility. In this clinician update, we discuss current options for inotropic therapy in HF, when it might be appropriate to use inotropes in HF patients, and what steps can be taken to mitigate their risks while maximizing benefit.A 68-year-old man with type II diabetes mellitus and ischemic cardiomyopathy (left ventricular ejection fraction, 25%) presents with dyspnea and increasing abdominal distension despite compliance with maximal medical therapy, adherence to fluid and sodium restrictions, and implantable cardioverter-defibrillator and cardiac resynchronization therapy. His creatinine has risen from 1.3 to 2.1 and his blood urea nitrogen from 20 to 52. Heart rate is paced at 70 bpm, blood pressure is 95/56 mm Hg, and jugular venous pressure is 12 cm H2O, with moderate ascites and edema. You elect to admit him to the hospital for further treatment, including intravenous loop diuretics. Should you also discontinue his β-blocker and start dobutamine?Answer to case: Most patients admitted with HF in the United States, even those with systolic dysfunction, have normal blood pressure and clearly do not require inotropes. On the other hand, the patient described in this case represents a challenging population in which acute HF is associated with deterioration in renal function (ie, cardiorenal syndrome).1 There …