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

μg/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 α1 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).

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, α1

and β1





May not improve RV ejection

fraction; arrhythmias

Norepinephrinea

α1 > β1

 or 



Decreased mortality in subgroup of

cardiogenic shock and decreased

rate of arrhythmias compared with

dopamine in a randomized trial

Phenylephrine

α1





Reflex bradycardia may be harmful

in the setting of RV failure

Epinephrine

α1, β1 > β2

 or 



Arrhythmias, hyperglycemia,

increased lactate concentrations

Vasopressin

V1 receptors



 or 

Use low dose (≤ 0.03 units/min)

Dobutamine

β1 > β2





Combine with peripheral

vasoconstrictor to attenuate

systemic vasodilation

Milrinone

PDE-3 inhibitor





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.