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Similar hemodynamic decongestion with vasodilators and inotropes: systematic review, meta-analysis, and meta-regression of 35 studies on acute heart failure

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Abstract

Background

Acute heart failure (AHF) with reduced left-ventricular ejection fraction (LVEF) is often a biventricular congested state. The comparative effect of vasodilators and inotropes on the right- and/or left-sided congestion is unknown.

Methods and results

A systematic review, meta-analysis, and meta-regression of AHF studies using pulmonary artery catheter were performed using PubMed, Embase, and Cochrane library. Data from 35 studies, including 3016 patients, were studied. Included patients had a weighted mean age of 60 years, left-ventricular ejection fraction (LVEF) of 24 %, and plasma B-type natriuretic peptide (BNP) of 892 pg/ml. Both the left- and right-ventricular filling pressures were elevated: weighted mean pulmonary artery wedge pressure (PAWP) was 25 mmHg (range 17–31 mmHg) and right atrial pressure (RAP) 12 mmHg (range 7–18 mmHg). Vasodilators and inotropes had similar beneficial effects on PAWP [−6.3 mmHg (95 % CI −7.4 to −5.2 mmHg) and −5.8 mmHg (95 % CI −7.6 to −4.0 mmHg), respectively] and RAP [−2.9 mmHg (95 % CI −3.8 to −2.1 mmHg) and −2.8 mmHg (95 % CI −3.8 to −1.7 mmHg), respectively]. Among inotropes, inodilators, such as levosimendan, have greater beneficial effect on the left-ventricular filling pressure than dobutamine. Drug-induced improvement of PAWP tightly paralleled that of RAP with all studied drugs (r 2 = 0.90, p < 0.001). Vasodilators and inotropes had no short-term effect of renal function.

Conclusion

The left- and right-sided filling pressures are similarly improved by vasodilators or inotropes, in AHF with reduced LVEF.

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Acknowledgments

AM received speaker’s honoraria from The Medicines Company, Novartis, Orion, Roche, Servier, Vifor Pharma; AM received fee as member of advisory board and/or Steering Committee from Cardiorentis, The Medicine Company, Adrenomed, MyCartis and Critical Diagnostics. EG received fee as member of advisory board from Magnisense and Adrenomed.

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Authors and Affiliations

  1. Cardiology Department, Steel Memorial Yawata Hospital, Kitakyushu, Japan

    Shiro Ishihara & Naoki Sato

  2. Inserm UMR-S 942, Paris, France

    Shiro Ishihara, Etienne Gayat, Mattia Arrigo, Said Laribi, Matthieu Legrand, Rui Placido, Philippe Manivet, Alain Cohen-Solal & Alexandre Mebazaa

  3. University Paris Diderot, Sorbonne Paris Cité, Paris, France

    Etienne Gayat, Said Laribi, Matthieu Legrand, Alain Cohen-Solal & Alexandre Mebazaa

  4. Department of Anesthesia and Critical Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France

    Etienne Gayat, Mattia Arrigo, Matthieu Legrand & Alexandre Mebazaa

  5. Division of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland

    Mattia Arrigo

  6. Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, Paris, France

    Said Laribi

  7. Hospital Santa Maria, Serv Cardiologia I, Lisbon Academic Medical Centre, CCUL, Lisbon, Portugal

    Rui Placido

  8. Department of Biochemistry, Lariboisière Hospital, 2, Rue A. Paré, 75475, Paris Cedex 10, France

    Philippe Manivet

  9. France Center for Biological Resources, Lariboisière Hospital, Paris, France

    Philippe Manivet

  10. Department of Cardiology, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France

    Alain Cohen-Solal

  11. Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA

    William T. Abraham

  12. The Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA

    Mariell Jessup

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  1. Shiro Ishihara
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392_2016_1009_MOESM1_ESM.pdf

Supplementary material 1 Suppl Fig. 1–4: Comparison of changes in systemic hemodynamics between inotropes and vasodilators. Suppl Fig. 5: Comparison of safety parameters between inotropes and vasodilators. Suppl Fig. 6: Change in creatinine levels after drug administration. Only trials were studied, vasodilators are in blue, inotropes in red, and placebo arms in green (PDF 434 kb)

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Ishihara, S., Gayat, E., Sato, N. et al. Similar hemodynamic decongestion with vasodilators and inotropes: systematic review, meta-analysis, and meta-regression of 35 studies on acute heart failure. Clin Res Cardiol 105, 971–980 (2016). https://doi.org/10.1007/s00392-016-1009-6

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