Author + information
- Maya Guglin, MD, PhD∗ ()
- ↵∗Gill Heart Institute, Mechanical Circulatory Support Program, Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky Albert B. Chandler Hospital, First Floor, Suite G100, 800 Rose Street, Lexington, Kentucky 40536
I have read with interest a recent meta-analysis by Nizamic et al. (1) of inotropes in heart failure. The authors concluded that inotropes improve functional status but do not impact survival. This conclusion is valid only if the studies included in the analysis adequately address the question. In fact, they do not.
The main reason for the use of inotropes is their unique ability to increase cardiac output. Guidelines of the American College of Cardiology (2) and other societies state that inotropes are indicated in cases of low-output syndrome. This is critical. If there is no low output, inotropes can provide no therapeutic benefit, although they can still produce side effects such as proarrhythmia. The OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations) found that milrinone did not affect mortality but increased side effects. The caveat was that patients were excluded if milrinone was considered essential for their management (3).
Nizamic et al. (1) selected 9 randomized controlled trials to analyze the effect of inotropes on mortality. Only 1 of the 9 trials required trial participants to have a cardiac index ≤2.2 l/min per m2 to qualify for the study (4). Cardiac output/index were not measured at all in the remainder of subjects, or a cardiac index of <2.5 l/min per m2 was required, which does not meet the criteria for low output. In addition, in the meta-analysis, trials from the era before implantable cardioverters-defibrillators were mixed with later studies, which could also compromise the results.
Unless inotropes are used to treat low-output syndrome and not a broadly defined “advanced heart failure,” their therapeutic effects, including mortality benefit, cannot be assessed.
Please note: Dr. Guglin has reported that she has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Nizamic T.,
- Murad M.H.,
- Allen L.A.,
- et al.
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