Need for hospice and palliative care services in patients with end-stage heart failure treated with intermittent infusion of inotropes.

BACKGROUND: Hospice and palliative care programs to relieve suffering and optimize management of terminally ill patients have grown rapidly in the United States. However, there are no data on the need for these services among patients with end-stage heart failure receiving intermittent infusion of intravenous inotropes. HYPOTHESIS: The need for hospice and palliative care programs among patients in end-stage heart failure who receive intermittent infusion of inotropes is investigated. METHODS: The study included all stable patients with refractory heart failure symptoms treated with inotropes in our outpatient unit. A total of 73 patients (65 +/- 12 years; left ventricular ejection fraction 22 +/- 9%; New York Heart Association class 3.6 +/- 0.4) were seen during a 49-month period. Of these, 35 patients (48%) met hospice or palliative care evaluation criteria upon referral but were offered, and accepted, the alternative of parenteral inotropes. In all, 1,737 individual outpatient treatment sessions were given, with a mean of 24 +/- 19 sessions per patient (range 5 to 118 sessions), representing a minimum of 9,948 h of inotrope therapy. RESULTS: A total of 18 (25%) patients died, 6 (8%) patients were withdrawn from the program (3 by their primary physicians and 3 because of significant travel limitations); 4 (5%) patients required continuous intravenous home therapy; and 44 (61%) patients were discharged with significant improvement in their heart failure symptoms. Only 7 of the 18 patients who died had received hospice or palliative care intervention, mainly for the sake of comfort and to ease the transition among family members. The rest of the patients were comfortable and had accepted the natural evolution of their disease; they were not interested in or did not require hospice or palliative care intervention. Of the patients discharged from the outpatient cardiac infusion unit, the interval free of heart failure symptoms after the final infusion treatment ranged from 201 to 489 days, with no need for hospitalization or emergency room visits. CONCLUSION: Our results demonstrate that intermittent infusion of intravenous inotropes can be safely administered and can improve symptoms in a significant number of patients, probably by slowing the natural progression of heart failure. Although the full clinical impact of inotrope therapy in an outpatient setting has not been fully defined, other nonhemodynamic-related benefits should be sought and investigated. Our results suggest that intermittent infusion of intravenous inotropes is one of the prominent variables that requires particular attention. In our experience, the institution of intermittent infusions of intravenous inotropes can, in fact, modify end-stage heart failure symptoms that, in most patients, are currently perceived to lead to a terminal event. Thus, appropriate use of intermittent infusion of intravenous inotropes may not only improve functional class and symptoms in a significant number of patients identified as terminal by their poor response to conventional therapy, but it may also facilitate better utilization of hospice and palliative care resources among patients with end-stage heart failure. Furthermore, the need for hospice and palliative care in patients with heart failure should be revisited in view of adjuvant treatment options such as intermittent infusion of intravenous inotropes.

Symptomatic improvement in patients treated with intermittent infusion of inotropes: a double-blind placebo controled pilot study.

The safety and benefit of outpatient inotrope infusions in intractable heart failure remains controversial. Accordingly a prospective double blind, crossover randomization scheme was utilized in stable patients with heart failure but intractable symptoms. A total of 29 patients (mean age 66 +/- 13 years, with a mean left ventricular systolic function of 18 +/- 9%, New York Heart Association class 3.6 +/- 0.5) met all the inclusion and none of the exclusion criteria to receive intravenous milrinone, dobutamine, or matching placebo. Safety evaluations including routine laboratory studies, physical examinations, electrocardiographic monitoring, vital signs, assessment of quality of life scores using the Minnesota Living with Heart Failure questionnaire, six-minute walk tests, and echocardiographic assessments were performed. All 29 patients completed the weaning protocol without adverse events (mean of 27.3 +/- 11.8 treatments per patient). Patients initially assigned to milrinone received fewer treatment sessions (19 +/- 8 versus 31 +/- 12 (dobutamine) and 33 +/- 10 (placebo); p<0.02. Furthermore, only 10% of the patients treated with milrinone required crossover randomization compared to 27% patients assigned to dobutamine and 75% patients assigned to placebo. A statistically significant reduction in quality of life scores (60 +/- 20 versus 35 +/- 18; p < 0.00001) with an increase in 6-minute walk test assessments (959 +/- 431 versus 1269 +/- 469; p < 0.01) was noted. Most importantly, in patients assigned to inotropes a 23% increase in 6-minute walk test scores was noted at the end of the study when compared to baseline scores. In contrast, a reduction of -1% (p < 0.001) was noted in patients assigned to placebo. Finally, a trend that although did not reached statistical significance was noted in patients assigned to milrinone in terms of improvement in left ventricular systolic function, reduction in the severity of mitral regurgitation and estimated right ventricular systolic pressure. These results demonstrate that outpatient infusion of inotropes appear to be safe and effective in improving heart failure symptoms, reducing need for hospitalizations and emergency room visits. Furthermore, infusion of inotropes resulted in a significant improvement on 6-minute walk test scores than placebo. It also appears that milrinone confers all these benefits sooner than dobutamine.

Intermittent infusion of inotropes in the outpatients setting: one-year post treatment analysis

The course of patients with New York Heart Association (NYHA) class III and IV and refractory heart failure symptoms is characterized by progressive clinical deterioration and frequent hospital readmissions. The value of intermittent intravenous administration of inotropes in managing this group of patients in the outpatient setting has been controversial. In this study, patients with refractory heart failure symptoms were enrolled to assess the impact of a multidisciplinary outpatient program in terms of on hospital admissions, emergency room visits, and interval free of symptoms after administration of inotropes. This is a retrospective analysis on 41 patients with refractory heartfailure treated at our outpatient cardiac infusion unit over a 20 month period. Thirteen patients with a NYHA class III [age 64 +/- 13; LVEF 27 +/- 9 percent] and 28 patients with a NYHA class IV [age 65 +/- 13 years; LVEF 21 +/- 9 percent], mostly males, were included. A total of 65 admissions for decompensated HF were recorded in the previous 6-months prior to initiation of the outpatient program; compared to only 4 emergency room visits and 7 hospital admissions after enrollment. Furthermore, 17 patients have been discharged with improvement in NYHA class from 3.5 +/ 0.6 to 1.4 +/- 0.5. On these patients, the interval free of symptoms since the last infusion treatment has ranged from 201 to 489 days, without emergency room visits or hospital admissions for congestive heart failure. The results of this study support the use of intermittent infusion of inotropes in the outpatient setting. Although the natural history for patients with refractory heart failure has been grim; the use of these intermittent infusions may in fact alter the natural course of end stage congestive heart failure patients and deserves further investigation.