Parenteral inotropic support for advanced congestive heart failure

Parenterally administered positive inotropic agents remain an important component of the therapeutics of cardiac dysfunction and failure. Dobutamine, a catechol, remains the prototype of this drug group, but recently has been joined by the phosphodiesterase III inhibitor, milrinone. Compared with dobutamine, milrinone has greater vasodilating-unloading properties. The catecholamine, dopamine, is often used as a parenteral positive inotrope; but at moderate to high dose, it evokes considerable systemic vasoconstriction. At lower doses, dopamine appears to augment renal function. Levosimendan and toborinone, new compounds with several mechanisms of action, are under active clinical investigation and review for approval. Parenteral positive inotropic therapy is indicated for short-term (hours to days) treatment of cardiovascular decompensation secondary to ventricular systolic dysfunction, low-output heart failure. More prolonged or continuous infusion of one of these agents may be necessary as a "pharmacologic bridge" to cardiac transplantation, another definitive intervention, or more advanced, intense medical therapy. An occasional patient will require a continuous infusion via indwelling venous catheter and portable pump, simply to be able to be discharged from the hospital setting and function in the home environment. Intermittent parenteral inotropic therapy for chronic heart failure has provoked considerable controversy and passion among cardiologists and heart failure specialists; an attempt is made to present this topic in an objective manner.