Cardiovascular Critical Care I

Dobutamine and milrinone are most often used for suspected or confirmed low cardiac output

states. Milrinone may be preferred more than dobutamine in the presence of recent administration

of β-blockade or in the setting of concomitant pulmonary hypertension (because of its post-β

receptor effects and potent vasodilatory properties, respectively). In terms of pharmacokinetic

differences, dobutamine has a faster onset and shorter half-life (2 min) compared with milrinone

(half-life of 3 hrs with renal-dependent elimination). However, no differences in clinical efficacy

or safety have been observed between agents. Both agents should be closely monitored for the

development of proarrhythmias and worsening ischemia.

Evaluate for the appropriate initiation of GDMT

Current guidelines recommend initiation of a 4-drug regimen for most patients with HFrEF as soon

as possible, including in the inpatient setting. This 4-drug regimen is a combination of a RAAS

inhibitor (angiotensin receptor/neprilysin inhibitor preferred), beta blocker, MRA, and sodium

glucose co-transporter 2 inhibitor. For further guidance on GDMT indications, please consult

current HF guidelines (Circulation 2022;145:e895-1032).

Many providers discontinue β-blockers in acute decompensated HF, but this practice is generally

not recommended because research indicates it can significantly increase the risk of in-hospital and

short-term mortality, given the potential for increased sympathetic nervous system activation upon

abrupt discontinuation. β-Blockers should be continued in patients with acute decompensated HF

unless there are specific clinical reasons to discontinue them, like severe hemodynamic instability

or evidence of shock (Eur Heart J. 2009;30(18):2186-2192).

management of the critically ill patient. Valvular heart disease can also independently lead to the presenting

critical illness.

depth and breadth of these etiologies are beyond the scope of this chapter. Nevertheless, conditions that may

require repair/replacement include those listed in Table 12.

Stenosis

Narrowing at the opening of the valve(s)

Can lead to concurrent regurgitation

Regurgitation

“Leaky” valve(s) resulting in less blood pumping forward through the heart

Prolapse

“Floppy” valve(s) with part of valve not working

Endocarditis

Infection of one or more valves

Malformation

Often occurs at birth when the valve (or valves) is defective

aValvular disease secondary to rheumatic heart disease is a rare but possible contributor.