Which medications in the drug class Inotropic Agents are used in the treatment of Dilated Cardiomyopathy?

Updated: Mar 02, 2021
  • Author: Vinh Q Nguyen, MD, FACC; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE  more...
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Inotropic Agents

Long-term use of the phosphodiesterase inhibitor milrinone has deleterious effects on survival in patients with heart failure. Improvement of CHF symptoms occurs as the trade-off for this increase in mortality. Inotropic agents are reserved for patients who need hemodynamic-directed treatment during acute decompensation, those refractory to maximal standard therapy, as palliation for end-stage heart failure, or as a bridge to transplantation for appropriate candidates. Milrinone may have an advantage over dobutamine in that it can be used for acute inotropic support during introduction of beta-blocker therapy, particularly in those who are beta-blocker intolerant due to the myocardial depressant effects.  [] 170]

Digoxin therapy for heart failure has no benefit on mortality rates. However, it does improve NYHA functional class, hemodynamics, symptoms, exercise capacity, and quality of life and reduces hospitalizations for heart failure. Patients with worse NYHA functional class and lower left ventricular ejection fraction benefit most from digoxin therapy.


Milrinone is a phosphodiesterase III inhibitor that prevents degradation of cAMP, ultimately leading to increased myocardial contraction and lusitropy, decreased pulmonary vascular resistance, and reduced afterload. It differs in mode of action from both digitalis glycosides and catecholamines. This agent is used for the short-term management of acute decompensated heart failure.


In patients with cardiogenic shock/decompensated heart failure due to myocardial dysfunction, dobutamine is a beta-agonist that may be acutely used to increase cardiac output. In those with low-flow heart failure, chronic dobutamine infusion may be considered in those awaiting transplant or for those who are not candidates for advanced therapies (transplant, ventricular assist device).

Note that chronic infusion may be associated with an increased mortality risk due to ventricular arrhythmias. 

Digoxin (Lanoxin)

Digoxin is a cardiac glycoside with direct inotropic effects in addition to indirect effects on the cardiovascular system. It acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.

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