Aronow, Wilbert S.

Positive inotropic agents have an important role in the management of acute decompensated heart failure patients with reduced cardiac output and poor end-organ perfusion. However, despite their acute hemodynamic benefits, the role of inotropes in the management of chronic advanced heart failure remains limited to palliative therapy or as a bridging strategy to mechanical support or heart transplantation. Milrinone is one of the most common inotropic agents used in advanced heart failure to provide symptomatic relief and improved hemodynamics. This review discusses the current evidence of milrinone’s efficacy, indications, outcomes in advanced heart failure, evidence gap, and future directions.

Hyperkalemia is a common and potentially life-threatening electrolyte abnormality in patients with heart failure, particularly among those with diabetes or chronic kidney disease. It often results from the use of renin–angiotensin–aldosterone system inhibitors, which, while improving survival, increase serum potassium levels. Elevated potassium produces cardiotoxic effects, often recognized by characteristic electrocardiographic changes. Acute management focuses on stabilizing cardiac membranes with intravenous calcium and shifting potassium intracellularly through insulin-dextrose, β₂-agonists, or sodium bicarbonate, with caution to avoid fluid overload. Potassium elimination may be achieved using diuretics or hemodialysis when refractory. For chronic management, newer potassium-binding agents such as patiromer and sodium zirconium cyclosilicate offer improved safety and efficacy compared with traditional resins, enabling the continuation and up-titration of renin–angiotensin–aldosterone system inhibitors. These therapies support optimal neurohormonal blockade, improve adherence, and reduce morbidity and mortality in heart failure.