Author + information
- Received December 1, 2017
- Revision received March 28, 2018
- Accepted March 28, 2018
- Published online August 27, 2018.
- Tiana Nizamic, MDa,
- M. Hassan Murad, MDb,
- Larry A. Allen, MD, MHSc,
- Colleen K. McIlvennan, DNP, ANPc,
- Sara E. Wordingham, MDd,
- Daniel D. Matlock, MD, MPHe and
- Shannon M. Dunlay, MD, MSf,∗ ()
- aDepartment of Medicine, University of Colorado at Denver, Denver, Colorado
- bDivision of Preventive, Occupational, and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- cDivision of Cardiology, Department of Medicine, University of Colorado, Denver, Colorado
- dSection of Palliative Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
- eDivision of Geriatrics, Department of Medicine, University of Colorado at Denver, Denver, Colorado
- fDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Shannon M. Dunlay, Mayo Clinic, 200 First Street South West, Rochester, Minnesota 55905.
Objectives This study sought to systematically review the available evidence of risks and benefits of ambulatory intravenous inotrope therapy in advanced heart failure (HF).
Background Ambulatory inotrope infusions are sometimes offered to patients with advanced Stage D HF; however, an understanding of the relative risks and benefits is lacking.
Methods On August 7, 2016, we searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for studies of long-term use of intravenous inotropes in outpatients with advanced HF. Meta-analysis was performed using random effects models.
Results A total of 66 studies (13 randomized controlled trials and 53 observational studies) met inclusion criteria. Most studies were small and at high risk for bias. Pooled rates of death (41 studies), all-cause hospitalization (15 studies), central line infection (13 studies), and implantable cardioverter-defibrillator shocks (3 studies) of inotropes were 4.2, 22.2, 3.6, and 2.4 per 100 person-months follow-up, respectively. Improvement in New York Heart Association (NYHA) functional class was greater in patients taking inotropes than in controls (mean difference of 0.60 NYHA functional classes; 95% confidence interval [CI]: 0.22 to 0.98; p = 0.001; 5 trials). There was no significant difference in mortality risk in those taking inotropes compared with controls (pooled risk ratio: 0.68; 95% CI: 0.40 to 1.17; p = 0.16; 9 trials). Data were too limited to pool for other outcomes or to stratify by indication (i.e., bridge-to-transplant or palliative).
Conclusions High-quality evidence for the risks and benefits of ambulatory inotrope infusions in advanced HF is limited, particularly when used for palliation. Available data suggest that inotrope therapy improves NYHA functional class and does not impact survival.
Dr. Dunlay’s contribution was supported by U.S. National Institutes of Health grant K23 HL 116643. Dr. Allen has financial relationships with Boston Scientific, Cytokinetics, Novartis, Patient-Centered Outcomes Research Institute (PCORI), National Institutes of Health, and the American Heart Association. Dr. Matlock has received support from the American College of Cardiology Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 1, 2017.
- Revision received March 28, 2018.
- Accepted March 28, 2018.
- 2018 American College of Cardiology Foundation
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