Il trattamento con farmaci ad azione inotropa positiva nella gestione del paziente con scompenso cardiaco cronico con frequenti instabilizzazioni

In patients with unstable advanced heart failure, diuretic therapy induces a series of compensatory mechanisms in the kidney, both intrinsic and mediated by the renin-angiotensin system, whose final purpose is the maintenance of sodium homeostasis. These mechanisms, however, in the presence of arterial hypotension due to low cardiac output, can lead to renal insufficiency. The dependence of glomerular filtration on the constriction of the efferent artery mediated by angiotensin II may render these patients intolerant to neurohormonal inhibition. In this condition, when decompensated heart failure with congestion and systemic hypoperfusion is present, inotropic drugs should be used. Since some of these patients cannot be weaned from inotropes, ambulatory inotropic therapy can be a “bridge” therapy to cardiac transplantation or to mechanical circulatory assist device implantation, or a permanent therapy when no other option exists. Dobutamine, alone or in association with dopamine, is the most frequently used inotropic agent; for this therapy, a permanent central venous access and a continuous infusion pump are needed, as well as frequent day-hospital admissions for the management of the infusion pump. Phosphodiesterase inhibitors are less frequently used for this purpose. Levosimendan, because of its long-lasting effect, can be administered every 3 to 4 weeks; in a series of reports as well as in our experience, levosimendan has proven effective in achieving clinical stability, and ameliorating echocardiographic data and outcome.