p.64 抽出テキスト
May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e958 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1. More prolonged use of inotropes as “bridge” therapy for those awaiting either heart transplantation or MCS may have benefit in reducing pulmonary hypertension and maintaining end-organ perfusion beyond initial stabilization of patients.1–4 2. The use of inotropes for palliation does carry with it risks for arrhythmias and catheter-related infections, although the presence of an ICD does decrease the mortality associated with arrhythmias. This risk should be shared with patients if there is planned use of inotropes in a patient without an ICD, or in whom the preference is to deactivate the ICD for palliative purposes. The rate of inappropriate shocks for sinus tachycardia is relatively low, and the concomitant use of beta blockers may help in these patients. Patients may elect to have their shocking devices deactivated, especially if they receive numerous shocks.14,15 3. With the currently available inotropic agents, the benefit of hemodynamic support and stabilization may be compromised by increased myocardial oxygen demand and increased arrhythmic burden. As newer agents are developed, more options may not have these known risks. There are investigational inotropic agents that may provide more options for the management of patients with HF and represent different classes of agents.16 8.4 Mechanical Circulatory Support Recommendations for Mechanical Circulatory Support Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 A 1. In select patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous intravenous inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, QOL, and survival.1–18 2a B-R 2. In select patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS can be beneficial to improve symptoms, improve functional class, and reduce mortality.2,4,7,10,12–17,19 Value Statement: Uncertain Value (B-NR) 3. In patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS devices provide low to intermediate economic value based on current costs and outcomes.20–24 2a B-NR 4. In patients with advanced HFrEF and hemodynamic compromise and shock, temporary MCS, including percutaneous and extracorporeal ventricular assist devices, are reasonable as a “bridge to recovery” or “bridge to decision.”25–29 Synopsis MCS is a therapeutic option for patients with advanced HFrEF to prolong life and improve functional capacity. Over the past 10 years, evolution and refinement of temporary and durable options has continued. MCS is differentiated by the implant location, approach, flow characteristics, Table 20. Intravenous Inotropic Agents Used in the Management of HF Inotropic Agent Dose (mcg/kg) Effects Bolus Infusion (/min) Drug Kinetics and Metabolism CO HR SVR PVR Adverse Effects Special Considerations Adrenergic agonists Dopamine NA 5–10 t1/2: 2–20 min ↑ ↑ ↔ ↔ T, HA, N, tissue necrosis Caution: MAO-I NA 10–15 R, H, P ↑ ↑ ↑ ↔ Dobutamine NA 2.5–20 t1/2: 2–3 min H ↑ ↑ ↔ ↔ ↑/↓BP, HA, T, N, F, hypersensitivity Caution: MAO-I; CI: sulfite allergy PDE 3 inhibitor Milrinone NR 0.125–0.75 t1/2: 2.5 h H ↑ ↑ ↓ ↓ T, ↓BP Accumulation may occur in setting of renal failure; monitor kidney function and LFTs Vasopressors Epinephrine NR 5–15 mcg/min t1/2: 2–3 min ↑ ↑ ↑ (↓) ↔ HA, T Caution: MAO-I 15–20 mcg/min t1/2: 2–3 min ↑ ↑↑ ↑↑ ↔ HA, T Caution: MAO-I Norepinephrine NR 0.5–30 mcg/min t1/2: 2.5 min ↔ ↑ ↑↑ ↔ ↓ HR, tissue necrosis Caution: MAO-I BP indicates blood pressure; CI, contraindication; CO, cardiac output; F, fever; H, hepatic; HA, headache; HF, heart failure; HR, heart rate; LFT, liver function test; MAO-I, monoamine oxidase inhibitor; N, nausea; NA, not applicable; NR, not recommended; P, plasma; PDE, phosphodiesterase; PVR, pulmonary vascular resistance; R, renal; SVR, systemic vascular resistance; T, tachyarrhythmias; and t1/2, elimination half-life. Up arrow means increase. Side arrow means no change. Down arrow means decrease. Up/down arrow means either increase or decrease. Downloaded from http://ahajournals.org by on October 7, 2026