Pulmonary Disorders II
Direct effects on the pulmonary circulation from vasopressors may increase the PVR, potentially
leading to further clinical decompensation.
Few studies have been published to help guide selection of the optimal vasopressor in patients with
PH; recommendations are extrapolations from other patient populations.
Experts recommend norepinephrine as the vasopressor of choice in decompensated PAH in
patients with low SVR because of its neutral impact on PVR at lower doses (less than 0.5
ΞΌg/kg/min) and reduced arrhythmogenic potential compared with dopamine (Heart Fail Rev.
2016;21(3):323-346; Eur Respir J. 2019;53(1):1801906).
ii.
Vasopressin can be considered as a first-line option or as an add-on to norepinephrine at
physiologic dosing (up to 0.03-0.04 units/min) in low SVR states because of its neutral effects
on PVR and ability to reduce norepinephrine requirements that may lead to the increased
PVR that can be seen with high doses (Heart Fail Rev. 2016;21(3):323-346; Eur Respir J.
2019;53(1):1801906).
iii.
Dopamine and epinephrine are second-line options because of the high risk of arrhythmia relative
to norepinephrine (Heart Fail Rev. 2016;21(3):323-346; Eur Respir J. 2019;53(1):1801906).
iv.
Phenylephrine should be avoided because of its isolated Ξ±1 activity that leads to unopposed
increases in PVR without augmentation of cardiac function (Heart Fail Rev. 2016;21(3):323-
346; Eur Respir J. 2019;53(1):1801906).
| d. | Inotropes are used to further augment the cardiac output of the RV and may improve PVR. Because |
|---|
of systemic vasodilatory properties from inotropes, expect possible systemic hypotension and need
for vasopressors.
Drug
Site of Action
(receptor activity)
Effects on PVR
Effects on CO
Comments
Dopamine
Dose-dependent
dopaminergic, Ξ±1
and Ξ²1
ο£
ο£
May not improve RV ejection
fraction; arrhythmias
Norepinephrinea
Ξ±1 > Ξ²1
ο£ or ο±
ο£
Decreased mortality in subgroup of
cardiogenic shock and decreased
rate of arrhythmias compared with
dopamine in a randomized trial
Phenylephrine
Ξ±1
ο£
ο±
Reflex bradycardia may be harmful
in the setting of RV failure
Epinephrine
Ξ±1, Ξ²1 > Ξ²2
ο£ or ο±
ο£
Arrhythmias, hyperglycemia,
increased lactate concentrations
Vasopressin
V1 receptors
ο±
ο£ or ο±
Use low dose (β€ 0.03 units/min)
Dobutamine
Ξ²1 > Ξ²2
ο€
ο£
Combine with peripheral
vasoconstrictor to attenuate
systemic vasodilation
Milrinone
PDE-3 inhibitor
ο€
ο£
Combine with peripheral
vasoconstrictor to attenuate
systemic vasodilation
Information from Hoeper 2019.
CO = cardiac output; PDE-3 = phosphodiesterase-3; PVR = pulmonary vascular resistance; RV = right ventricular.