Diastolic Dysfunction among HIV Infected African American Population

Abstract

Background: Ambulatory intravenous inotrope infusions are sometimes offered to patients with advanced stage D heart failure (HF); however, a contemporary evidence synthesis of the relative risks and benefits of chronic outpatient inotropes infusions is lacking. Methods: We searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for trials and observational studies of long-term use of intravenous inotrope infusions (milrinone, dobutamine, dopamine, levosimendan) in outpatients with advanced HF. Meta-analysis was performed where appropriate using random effects models. Results: A total of 66 studies including 3587 patients (median 36 patients per study) met inclusion criteria, including 13 randomized controlled trials (RCTs), 4 nonrandomized trials, and 49 observational studies. The indication for inotropes was bridge to transplant (BTT) in 11 studies, palliative in 8 studies, a combination of BTT and palliative in 13 studies, and not specified in 34 studies. Inotropes were administered intermittently (42 studies) and continuously (30 studies). Most studies were at high risk for bias. The pooled rate of death on inotropes was 4.4 per 100 person-months follow-up (95% CI 3.5-5.5; 46 studies). There was no difference in mortality in patients treated with inotropes compared with controls (pooled RR 0.68 CI 0.40-1.17, P = .16; 9 RCTs). On average, patients treated with inotropes had an improvement of 1.2 New York Heart Association (NYHA) functional classes (95% CI 1.0-1.4, P < .001; 24 studies), and the improvement was of greater magnitude in patients treated with inotropes compared to controls (mean difference 0.6 NYHA functional classes, 95% CI 0.2-1.0, P = .002; 5 RCTs). The pooled rates of all-cause hospitalizations (15 studies), central line infection (15 studies), and ICD shocks (3 studies) on inotropes were 22.2, 4.6, and 2.4 per 100 per-months follow-up, respectively. Outpatient inotropes were costsaving compared to ongoing hospitalization while awaiting cardiac transplantation (5 studies) but no studies compared costs of outpatient inotropes as palliation with other strategies such as hospice. Studies comparing patients on inotropes with controls were too limited to draw conclusions on outcomes including quality of life, hospitalization, and ventricular arrhythmias. Conclusion: High-quality evidence about the risks and benefits of ambulatory inotropes infusions in patients with advanced HF is limited, particularly when used for palliation. While available data suggest that outpatient inotrope infusions are associated with improvement in NYHA functional class with no impact on risk of death, there is insufficient evidence to determine how inotropes impact other important outcomes such as hospitalization and quality of life. RCTs or welldesigned observational studies of inotrope infusions for palliation compared with other strategies are needed.