Dobutamine in the Management of Advanced Heart Failure.

Background: The potential harm and clinical benefits of inotropic therapy in patients with decompensated heart failure with reduced ejection fraction or advanced heart failure were debated for three decades. Nonetheless, confronted with a dismal quality of life in the last months to years of life, continuous home inotropic therapy has recently gained traction for palliative therapy in patients who are not candidates for left ventricular mechanical circulatory support or heart transplantation. Methods: As continuous inotropic therapy is only considered for patients who experience symptomatic relief and display objective evidence of improvement, clinical equipoise is no longer present, and randomized controlled trials are hard to conduct. Results: We first outline the transient use of inotropic therapy in patients with decompensated heart failure with reduced ejection fraction and emphasize the hemodynamic requisite for inotropic therapy, which is a demonstration of a low cardiac output through a low mixed venous oxygen saturation. Lastly, we review the current experience with the use of home inotropic therapy in patients who are not candidates or are awaiting mechanical circulatory support or heart transplantation. Conclusions: Evidence-based clinical data are needed to guide inotropic therapy for refractory decompensated heart failure with reduced ejection fraction in patients who are ineligible or awaiting mechanical circulatory support or heart transplantation.

Post-COVID Sequelae: From Lung Disease to Long Disease.

COVID-19 can have both an acute phase and post-acute phase of illness termed post-COVID sequelae, or "long Covid." In this case, a 66-year-old woman with a past medical history of reactive airway disease was admitted for shortness of breath twice. The first episode occurred in the setting of active COVID-19 infection. However, the second episode took place seven weeks later in the absence of COVID-19 as evidenced by a rapid antigen test. It is unclear why she re-developed shortness of breath after being discharged symptom-free from her initial admission. After treatment with prednisone, albuterol, and ipratropium she experienced symptomatic relief yet again and outpatient pulmonary function testing demonstrated a mildly obstructive pattern reversed with an inhaled bronchodilator. She has remained symptom-free since finishing an outpatient prednisone course. It is possible she developed post-COVID sequelae resembling an acute asthma exacerbation. Though the exact mechanism of post-COVID sequelae is not known, it is thought to be due to a combination of immune activation, dysregulation, and suppression. It is an important presentation for internists to know given the prevalence of COVID-19.

Severe Shivering as an Adverse Effect of Regadenoson Myocardial Perfusion Imaging.

Regadenoson myocardial perfusion imaging (MPI) is a widely used screening study for patients with an intermediate pretest probability of coronary artery disease (CAD). Via selective agonism of the adenosine A2A receptor, regadenoson can induce coronary steal, revealing stenotic vessel territory through transient ischemia. Common side effects of this medication include chest pain, shortness of breath, nausea, vomiting, atrioventricular block, seizure, and allergic reactions. Here we present a case of severe shivering and chest tightness after the administration of regadenoson, along with a physiologic explanation and treatment.