Inhaled pulmonary vasodilators in acute heart failure and cardiogenic shock decreased mean pulmonary artery pressure by 7.55 mmHg and increased cardiac index by 0.42 L/min/m² (p<0.0001).
Do inhaled pulmonary vasodilators improve hemodynamics in adults with acute heart failure or cardiogenic shock?
Inhaled pulmonary vasodilators significantly improve pulmonary hemodynamics and cardiac output in patients with acute heart failure and cardiogenic shock, though their impact on mortality remains to be established.
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Abstract Rationale Acute heart failure (AHF) and cardiogenic shock (CS) complicated by pulmonary hypertension (PH) and right ventricular dysfunction (RVD) carry high mortality. Inhaled pulmonary vasodilators (iPVDs), including nitric oxide (iNO) and prostacyclins, are increasingly used in cardiac intensive care units, yet evidence remains fragmented across heterogeneous populations. This meta-analysis synthesizes available evidence on hemodynamic efficacy and clinical outcomes of iPVDs in AHF and CS. Methods We conducted a systematic review following PRISMA guidelines, searching PubMed, Embase, and Cochrane CENTRAL through November 2025 for studies evaluating iPVDs in adults with AHF or CS. Two independent reviewers screened studies and extracted data. Study quality was assessed using the Cochrane Risk of Bias 2.0 tool for RCTs and Newcastle-Ottawa Scale for observational studies. Primary outcomes were changes in cardiac index (CI) and mean pulmonary artery pressure (mPAP). Secondary outcomes included pulmonary vascular resistance (PVR) and in-hospital mortality. Random-effects models were used for meta-analysis. Heterogeneity was assessed using I² statistics. Prespecified subgroup analyses by study design were performed. Results We included 17 studies (6 RCTs, 11 observational) comprising 755 patients. Populations included post-cardiac surgery, heart transplant recipients, LVAD recipients, and CS on mechanical circulatory support. In the overall analysis, iPVD use was associated with significant hemodynamic improvements: mPAP decreased by -7.55 mmHg (95% CI: -8.57 to -6.54; p 0.0001; I²=82.7%; n = 12 studies), CI increased by 0.42 L/min/m² (95% CI: 0.34 to 0.50; p 0.0001; I²=91.1%; n = 11 studies), and PVR decreased by -135 dyne·s·cm-5 (95% CI: -151 to -120; p 0.0001; I²=77.7%; n = 12 studies). Despite high heterogeneity in the overall analysis, subgroup analysis restricted to RCTs (n = 5 for each outcome) demonstrated reduced heterogeneity: mPAP -6.31 mmHg (95% CI: -7.26 to -5.37; I²=68.5%), CI + 0.46 L/min/m² (95% CI: 0.34 to 0.57; I²=93.8%), and PVR -123 dyne·s·cm-5 (95% CI: -135 to -111; I²=30.8%). Pooled in-hospital mortality from 4 studies (n = 409 patients) was 18.8%. Conclusions In patients with AHF and CS, iPVDs significantly improve pulmonary hemodynamics and cardiac output. Subgroup analysis of RCTs demonstrated low heterogeneity for PVR (I²=30.8%) and moderate heterogeneity for mPAP (I²=68.5%), supporting consistent treatment effects for pulmonary vascular outcomes across high-quality studies, though cardiac index responses showed greater variability. These findings support iPVDs as a therapeutic adjunct in this high-risk population. Large-scale RCTs are needed to evaluate impact on mortality and identify optimal patient selection criteria. This abstract is funded by: none
Jain et al. (Fri,) reported a other. Inhaled pulmonary vasodilators in acute heart failure and cardiogenic shock decreased mean pulmonary artery pressure by 7.55 mmHg and increased cardiac index by 0.42 L/min/m² (p<0.0001).