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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e957 CLINICAL STATEMENTS AND GUIDELINES

8.3 Inotropic Support

Recommendations for Inotropic Support Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

2a B-NR 1.	 In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as “bridge therapy.”1–4

2b B-NR 2.	 In select patients with stage D HF, despite optimal GDMT and device therapy who are ineligible for either MCS or cardiac transplantation, continuous intravenous inotropic support may be considered as palliative therapy for symptom control and improvement in functional status.5–7

3: Harm B-R 3.	 In patients with HF, long-term use of either continuous or intermittent intravenous inotropic agents, for reasons other than palliative care or as a bridge to advanced therapies, is potentially harmful.5,6,8–11

Synopsis Despite improving hemodynamic compromise, positive inotropic agents have not shown improved survival in patients with HF in either the hospital or the outpatient setting.6 Regardless of their mechanism of action (eg, inhibition of phosphodiesterase, stimulation of adrenergic or dopaminergic receptors, calcium sensitization), parenteral inotropes remain an option to help the subset of patients with HF who are refractory to other therapies and are suffering consequences from end-organ hypoperfusion. In hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly low cardiac index, short-term, continuous intravenous inotropic support may be reasonable to maintain systemic perfusion and preserve end-organ performance.8,11,12 There continues to be lack of robust evidence to suggest the clear benefit of 1 inotrope over another.13 To minimize adverse effects, lower doses of parenteral inotropic drugs are preferred, although the development of tachyphylaxis should be acknowledged, and the choice of agent may need to be changed during longer periods of support. Similarly, the ongoing need for inotropic support and the possibility of discontinuation should be regularly assessed. Table 20 compares commonly used inotropes.

Table 18.  Clinical Indicators of Advanced HF1,2,12,13,23–37 Repeated hospitalizations or emergency department visits for HF in the past 12 mo. Need for intravenous inotropic therapy. Persistent NYHA functional class III to IV symptoms despite therapy. Severely reduced exercise capacity (peak VO2, <14 mL/kg/min or <50% predicted, 6-min walk test distance <300 m, or inability to walk 1 block on level ground because of dyspnea or fatigue). Intolerance to RAASi because of hypotension or worsening renal function. Intolerance to beta blockers as a result of worsening HF or hypotension. Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d or use of supplemental metolazone therapy. Refractory clinical congestion. Progressive deterioration in renal or hepatic function. Worsening right HF or secondary pulmonary hypertension. Frequent SBP ≤90 mm Hg. Cardiac cachexia. Persistent hyponatremia (serum sodium, <134 mEq/L). Refractory or recurrent ventricular arrhythmias; frequent ICD shocks. Increased predicted 1-year mortality (eg, >20%) according to HF survival models (eg, MAGGIC,21 SHFM22). HF indicates heart failure; ICD, implantable cardioverter-defibrillator; MAG- GIC, Meta-analysis Global Group in Chronic Heart Failure; NYHA, New York Heart Association; RAASi, renin-angiotensin-aldosterone system inhibitors; SBP, systolic blood pressure; SHFM, Seattle Heart Failure model; and VO2, oxygen consumption/oxygen uptake. Table 19.  Indications and Contraindications to Durable Mechanical Support37

Indications (combination of these): Frequent hospitalizations for HF NYHA class IIIb to IV functional limitations despite maximal therapy Intolerance of neurohormonal antagonists Increasing diuretic requirement Symptomatic despite CRT Inotrope dependence Low peak VO2 (<14–16) End-organ dysfunction attributable to low cardiac output Contraindications: Absolute Irreversible hepatic disease Irreversible renal disease Irreversible neurological disease Medical nonadherence Severe psychosocial limitations Relative Age >80 y for destination therapy Obesity or malnutrition Musculoskeletal disease that impairs rehabilitation Active systemic infection or prolonged intubation Untreated malignancy Severe PVD Active substance abuse Impaired cognitive function Unmanaged psychiatric disorder Lack of social support CRT indicates cardiac resynchronization therapy; HF, heart failure; NYHA, New York Heart Association; VO2, oxygen consumption; and PVD, peripheral vascular disease.

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