Rationale for the Short Term Use of Intravenous Milrinone Under Hemodynamic Guidance in Patients With Severe Systolic Heart Failure

Patients with severe systolic heart failure have a decrease in both number and function of cardiac beta receptors, which may result in a poor inotropic response to I.V. beta-adrenergic agonists such as dobutamine. The I.V. use of the phosphodiesterase inhibitor milrinone, which is a combined positive inotrope/vasodilator in this patient population, is a more rational choice, especially if heart failure is chronic. Many of these patients may also be referred for consideration for cardiac transplantation, for which the use of invasive hemodynamic monitoring is typically necessary to determine whether severe hemodynamic compromise and pulmonary hypertension are reversible with therapy. The use of hemodynamically guided I.V. vasodilator therapy has also been extensively described as a tool to optimize oral vasodilator therapy and predict prognosis in patients evaluated for cardiac transplantation. This review summarizes the important studies supporting the rationale for and benefits of using I.V. milrinone under hemodynamic guidance in this patient population.