Heart Failure Unit, Attikon University Hospital, Athens, Greece.
Curr Opin Crit Care. 2010 Oct;16(5):432-41. doi: 10.1097/MCC.0b013e32833e10fb.
ICU patients frequently develop low output syndromes due to cardiac dysfunction, myocardial injury, and inflammatory activation. Conventional inotropic agents seem to be useful in restoring hemodynamic parameters and improving peripheral organ perfusion, but can increase short-term and long-term mortality in these patients. Novel inotropes may be promising in the management of ICU patients, having no serious adverse effects. This review summarizes all the current knowledge about the use of conventional and new inotropic agents in various clinical entities of critically ill patients.
In recent European Society of Cardiology guidelines, inotropic agents are administered in patients with low output syndrome due to impaired cardiac contractility, and signs and symptoms of congestion. The most recommended inotropes in this condition are levosimendan and dobutamine (both class of recommendation: IIa, level of evidence: B). Recent data indicate that levosimendan may be useful in postmyocardial infarction cardiac dysfunction and septic shock through increasing coronary flow and attenuating inflammatory activation, respectively. Furthermore, calcium sensitizing by levosimendan can be effectively used for weaning of mechanical ventilation in postcardiac surgery patients and has also cardioprotective effect as expressed by the absence of troponin release in this patient population. Finally, new agents, such as istaroxime and cardiac myosin activators may be safe and improve central hemodynamics in experimental models of heart failure and heart failure patients in phase II clinical trials; however, large-scale randomized clinical trials are required.
In an acute cardiac care setting, short-term use of inotropic agents is crucial for the restoration of arterial blood pressure and peripheral tissue perfusion, as well as weaning of cardiosurgery. New promising agents should be tested in randomized clinical trials.
由于心功能障碍、心肌损伤和炎症激活，ICU 患者常发生低心输出综合征。传统的正性肌力药物似乎可用于恢复血流动力学参数和改善外周器官灌注，但会增加这些患者的短期和长期死亡率。新型正性肌力药物在 ICU 患者的治疗中可能具有广阔前景，因其没有严重的不良反应。本综述总结了关于传统和新型正性肌力药物在各种危重症患者临床实体中的应用的最新知识。
在最近的欧洲心脏病学会指南中，在因心脏收缩功能障碍和充血体征和症状导致低心输出综合征的患者中使用正性肌力药物。在这种情况下，最推荐的正性肌力药物是左西孟旦和多巴酚丁胺（均为推荐类别：IIa，证据水平：B）。最近的数据表明，左西孟旦通过增加冠状动脉血流和减轻炎症激活，分别对心肌梗死后心功能障碍和脓毒症性休克可能有用。此外，左西孟旦的钙敏化可有效用于心脏手术后患者的机械通气脱机，并且在该患者人群中也具有心肌保护作用，表现为肌钙蛋白释放缺失。最后，新的药物，如伊司罗莫司和心肌肌球蛋白激活剂，可能是安全的，并可改善心力衰竭和心力衰竭患者的 II 期临床试验中中心血流动力学；然而，需要进行大规模随机临床试验。
在急性心脏护理环境中，短期使用正性肌力药物对于恢复动脉血压和外周组织灌注以及心脏手术的脱机至关重要。新的有前途的药物应在随机临床试验中进行测试。
