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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Tag: heart failure

Inotropes and vasopressors


Inotropic agents are used to increase myocardial contraction while vasopressors are used to increase vascular tone. They are often used for treatment of patients whose tissue perfusion is insufficient to meet metabolic requirements. Therefore, these agents are usually administered in intensive care units where continuous and invasive monitoring of cardiac function can be applied.

Inotropic agents can be divided into those that increase cAMP levels and those that do not. Adrenergic receptor agonists and phosphodiesterase inhibitors (PDEi) increase cAMP levels and are currently the mainstay of positive inotropic therapy. Levosimendan acts as calcium sensitizer and increases myocardial contraction force without increasing intracellular calcium levels. In addition to existing inotropic agents, new promising inotropes are being developed. These include sarcoplasmic reticulum calcium pump (istaroxime), cardiac myosin activators (omecamtivmecarbil), gene therapy, nitroxyl donors and ryanodine receptor stabilizers.

Current treatments of heart failure are aimed at prolonging survival and not just alleviating symptoms. This review provides a short description of the physiology of myocardial contraction and adrenergic receptors. We also provide a short description of commonly used inotropic agents and vasopressor drugs as well as a short review of agents that are expected are in use in the future.

Inotropes are agents used to increase myocardial contractility, while vasopressors are administered to increase vascular tone(1).Their use ismostly confined to critically ill patients whose hemodynamic impairment is such that tissue perfusion is insufficient to meet metabolic requirements(2). Patients in need of inotropic or vasopressor support are often presented with septic or cardiogenic shock and severe heart failure, and are victims of major trauma or undergoing major surgery.These drugs are therefore administered usually to patients treated in intensive care settings where continuous monitoring of cardiac rhythm, arterial oxygenation, urine output and other invasive hemodynamic monitoring can be applied.Inotropic and vasopressor drugs should be administered through a central venous catheter via infusion pumps that can deliver precise flow rates. These agents are mostly short acting with rapid onset and offset of action. Therefore, they can be used without an initial bolus and can be titrated frequently. Abrupt discontinuation should be avoided because of possible hypotension.

Key words: Inotropes, Vasopressor Agents, Intensive Care, Heart Failure

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Clinical application of lung ultrasound in emergency department patients for the evaluation of pulmonary congestion: a comparison with chest X-ray


Introduction. Lung ultrasound can effectively rule out pulmonary edema when there is an absence of multiple B-lines and enables emergency physicians to improve their diagnostic performance, optimize therapeutic strategy, help early diagnosis for the patient and reduced hospital stay. The primary endpoint of this pilot study was to evaluate the effectiveness of lung ultrasound for diagnosing acute heart failure, even when used by emergency medicine residents, and assess the accuracy of B-line lung ultrasound in comparison to chest X-ray in emergency department patients.

Materials and methods. We enrolled 18 patients consecutively as they arrived at the Emergency Department of Clinical Hospital „Sveti Duh“, Croatia, presenting with undifferentiated acute dyspnea. Positive ultrasound confirmation of acute heart failure was defined as the bilateral existence of 2 or more positive regions with 3 or more B-lines.

Results. We found positive results regarding B-lines profile in 6 patients and cardiac decompensation was confirmed by their chest x-ray findings. The remaining 12 patients did not have B-lines by the LUS examination, neither signs of pulmonary congestion by their chest x-ray examination.

Conclusion. Lung ultrasound, given its practicability, simplicity and reproducibility, used by non-experts in emergency ultrasound, is a reliable tool for clinical examination of patients with acute heart failure.

Key words: emergency department, ultrasonography, heart failure, extravascular lung water

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Volume assessment in heart failure – a review


Heart failure represents a significant medical and economic burden and is also an important cause of mortality and morbidity. The advances in treating coronary artery disease mainly pertaining to modern invasive cardiology significantly reduced the mortality from coronary atherosclerosis, but on the other side caused an increase in incidence and prevalence of congestive heart failure. Heart failure is a disease of the elderly. In that population the incidence is 10 in 1000 patients older than 65 years and has a high five-year mortality despite all modern treatment modalities. (1)

Key words: heart failure, physical examination, congestion

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NTpro-BNP – diagnostic significance and recommended clinical applications


Brain natriuretic peptides are elevated in circulation in proportion to a decrease in myocardial function. They have been uniformly shown to have excellent negative predictive value in differential diagnosis of dyspnoea. They can also be used in diagnosing heart failure and have been recently shown as possible prognostic markers in acute coronary syndrome and pulmonary embolism. It is important to note that brain natriuretic peptide values rise with age and are inversely proportional to body mass index and glomerular filtration rate.

Key words: Brain natriuretic peptide N-terminal brain natriuretic peptide, heart failure

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Liver injury after the intravenous amiodarone administration in patient with impaired heart function


While many adverse effects have been associated with long-term oral amiodarone therapy, acute hepatotoxicity from intravenous administration of amiodarone is a rare side effect. This case report focuses on a 78-year-old critically ill female, who underwent several urgent surgical procedures and had elevated liver aminotransferases concentrations after the intravenous administration of amiodarone for the treatment of atrial fibrillation. Also, the patient developed heart failure with reduced left ventricular systolic function. Immediately after the discontinuation of amiodarone therapy, liver aminotransferases levels began to decline. Our case suggests that regular monitoring of hepatic function is required in patients receiving intravenous amiodarone, especially in the setting of impaired heart function and possible liver hypoperfusion.

Key words: amiodarone, hepatotoxicity, heart failure.

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