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


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 (r2= 0.90, p < 0.001). Vasodilators and inotropes had no short-term effect of renal function.


CONCLUSIONS
The left- and right-sided filling pressures are similarly improved by vasodilators or inotropes, in AHF with reduced LVEF.
Cardiology Department, Steel Memorial Yawata Hospital, Kitakyushu, Japan.|Inserm UMR-S 942, Paris, France.
Shiro
S
Ishihara
Inserm UMR-S 942, Paris, France.|University Paris Diderot, Sorbonne Paris Cité, Paris, France.|Department of Anesthesia and Critical Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.
Etienne
E
Gayat
Cardiology Department, Steel Memorial Yawata Hospital, Kitakyushu, Japan.
Naoki
N
Sato
Inserm UMR-S 942, Paris, France.|Department of Anesthesia and Critical Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.|Division of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.
Mattia
http://orcid.org/0000-0003-4028-2869
M
Arrigo
Inserm UMR-S 942, Paris, France.|University Paris Diderot, Sorbonne Paris Cité, Paris, France.|Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, Paris, France.
Said
S
Laribi
Inserm UMR-S 942, Paris, France.|University Paris Diderot, Sorbonne Paris Cité, Paris, France.|Department of Anesthesia and Critical Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.
Matthieu
M
Legrand
Inserm UMR-S 942, Paris, France.|Hospital Santa Maria, Serv Cardiologia I, Lisbon Academic Medical Centre, CCUL, Lisbon, Portugal.
Rui
R
Placido
Inserm UMR-S 942, Paris, France.|Department of Biochemistry, Lariboisière Hospital, 2, Rue A. Paré, 75475, Paris Cedex 10, France.|France Center for Biological Resources, Lariboisière Hospital, Paris, France.
Philippe
P
Manivet
Inserm UMR-S 942, Paris, France.|University Paris Diderot, Sorbonne Paris Cité, Paris, France.|Department of Cardiology, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France.
Alain
A
Cohen-Solal
Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA.
William T
WT
Abraham
The Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
Mariell
M
Jessup
Inserm UMR-S 942, Paris, France. alexandre.mebazaa@aphp.fr.|University Paris Diderot, Sorbonne Paris Cité, Paris, France. alexandre.mebazaa@aphp.fr.|Department of Anesthesia and Critical Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France. alexandre.mebazaa@aphp.fr.
Alexandre
A
Mebazaa
D002316:Cardiotonic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D009200:Myocardial Contraction / Q000187:drug effects*; D020127:Recovery of Function; D013318:Stroke Volume / Q000187:drug effects; D016896:Treatment Outcome; D014664:Vasodilation / Q000187:drug effects*; D014665:Vasodilator Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D016277:Ventricular Function, Left / Q000187:drug effects*; D016278:Ventricular Function, Right / Q000187:drug effects*; D017725:Ventricular Pressure / Q000187:drug effects
D002316:Cardiotonic Agents; D014665:Vasodilator Agents
Acute heart failure; Congestion; Decongestion; Hemodynamics; Inotropes; Meta-analysis; Meta-regression; Vasodilators