Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy.

Inotropes improve symptoms in advanced heart failure (HF) but were associated with higher mortality in clinical trials. Recurrent hospitalizations, arrhythmias, and infections contribute to morbidity and mortality, but the risks of these complications with modern HF therapies are not well known. We collected arrhythmia, infection, and hospitalization data on 197 patients discharged from our institution from January 2007 to March 2013 on intravenous inotropes. Patients were followed until they died, received a transplant or left ventricular assist device, were weaned off inotropes, or remained on inotropes at the end of the study. All patients had stage D HF. At baseline, 30% had a history of ventricular tachycardia, 7.1% had a history of cardiac arrest, and 39% had a history of atrial fibrillation. During follow-up, 33 patients (17%) had one or more implantable cardioverter-defibrillator shocks. Of patients who had shocks, 27 patients (82%) had appropriate shocks for ventricular tachycardia/ventricular fibrillation, 3 patients (9%) had inappropriate shocks, and 3 patients (9%) had both appropriate and inappropriate shocks. The risk of implantable cardioverter-defibrillator shock was not related to dose of inotrope (p = 0.605). Fifty-seven patients (29%) had one or more infections during follow-up. Bacteremia was the most common type of infection. Implanted electrophysiology devices did not confer an increased risk of infection. One hundred twelve patients (57%) had one or more hospitalizations during follow-up. Common causes of hospitalizations were worsening HF symptoms (41%), infections (20%), and arrhythmias (12%). In conclusion, arrhythmias, infections, and rehospitalizations are important complications of inotropic therapy.

Clinical Characteristics and Outcomes of Intravenous Inotropic Therapy in Advanced Heart Failure.

BACKGROUND: Inotrope use in heart failure treatment was associated with improved symptoms, but worse survival in clinical trials. However, these studies predated use of modern heart failure therapies. This study evaluates contemporary outcomes on long-term inotropes. METHODS AND RESULTS: We collected baseline and postinotrope data on 197 patients discharged on inotropes between January 2007 and March 2013. Baseline characteristics, hemodynamic and clinical changes on inotropes, and survival were evaluated. Patients initiated on inotropes had refractory heart failure, with median baseline New York Heart Association class IV, cardiac index of 1.7 L/min per m(2), pulmonary capillary wedge pressure of 25.6 mm Hg, and left ventricular ejection fraction of 18.7%. Inotropes were used in patients listed for transplant or scheduled for left ventricular assist device (LVAD; 60 patients), in patients being evaluated for LVAD/transplant (20 patients), for stabilization pending cardiac resynchronization therapy/percutaneous coronary intervention (4 patients), in patients who were offered LVAD but chose inotropes (15 patients), and for palliation (98 patients). Milrinone was used in 84.8% and dobutamine in 15.2%. At the end of the study, 68 patients had died, 24 were weaned off inotropes, 23 were transplanted, 32 received LVADs, and 50 remained on inotropes. Patients who received inotropes for palliation or those who preferred inotropes over LVAD had median survival of 9.0 months (interquartile range, 3.1-37.1 months), actuarial 1-year survival of 47.6%, and 2-year survival of 38.4%. Of 60 patients who were placed on inotropes as a bridge to transplant/LVAD, 55 were successfully maintained on inotropes until transplant/LVAD. CONCLUSIONS: Survival on inotropes for patients who are not candidates for transplant/LVAD is modestly better than previously reported, but remains poor. Inotropes are effective as a bridge to transplant/LVAD.