Palliative Inotrope Therapy

Abstract

eart failure (HF) affects more than 6 million individuals in the United States, 1,2 only a small fraction of whom receive heart transplant (HT) or mechanical circulatory support (MCS) such as left ventricular assist devices (LVADs). [3][4][5][6] Patients with advanced or stage D HF are subject to exceptionally high mortality. In a 2018 contemporary study of 969 patients with advanced HF who had not previously received advanced therapies or inotropes, 3-year mortality rate ranged from 26% to 44% depending on the severity of clinical presentation. 7 However, epidemiologic data about survival in patients with advanced HF are very limited. Importantly, patients with symptomatic HF also have significant morbidity, experiencing a similar burden of physical and depressive symptoms to patients with advanced cancer. 8 For a subset of patients with advanced HF with reduced ejection fraction (HFrEF), ambulatory intravenous inotropic support may be considered as a palliative therapy.Concerns about harm have generally kept continuous ambulatory inotrope use low in the last 2 decades. 9 However, presumably owing to ongoing unmet palliative needs and some recent publications about the potential benefit of targeted use for palliation, between 2010 and 2014, there was a 63% (from approximately 1200 to 2000 beneficiaries) and 44% (from approximately 400 to 575 beneficiaries) increase in the number of Medicare beneficiaries re-ceiving home milrinone and home dobutamine, respectively. 10 Still, health care professionals face uncertainty when considering initiation of ambulatory inotropes for palliation, given the paucity of robust data and guideline support as well as logistical issues, particularly if hospice is also desired. [11][12][13][14] The purpose of this review is to provide guidance to clinicians on initiation, selection, maintenance, and weaning or withdrawal of chronic inotropes and the management of concurrent therapies in the modern HF landscape. Historical PerspectiveIn the 1970s and 1980s, several studies demonstrated positive effects of intravenous inotropes on hemodynamics and symptoms. [15][16][17] Subsequent trials in the 1990s and early 2000s, including PROMISE, 18 FIRST, 19 VEST, 20 OPTIME, 21 and REVIVE II, 22 showed that the use of intravenous or oral inotrope therapy in acute or chronic HF was consistently associated with decreased survival and/or an increased risk of adverse cardiovascular events. In some of these studies, 6-month mortality was in excess of 50%.However, those studies were not designed to address use of inotropes as palliation. They also preceded the current era of modern HF therapies including implantable cardioverter defibrillators (ICDs), IMPORTANCE The number of patients living with end-stage heart failure is steadily growing, and ambulatory intravenous inotropic support is increasingly offered as a palliative therapy. However, the optimal ways to initiate, manage, and discuss the risks and benefits of palliative inotropes in the current era of heart failure care are unclear.OBSERVATION...

Terapia inotrópica em pacientes com insuficiência cardíaca crônica avançada

“…No entanto, há uma contradição na recomendação classe III, uma vez que define como não recomendado o uso contínuo ou intermitente de inotrópicos. Assim, no dia a dia torna-se difícil identificar quais pacientes apresentarão benefícios no uso dessas medicações, precisando considerar vários fatores para tomada dessa decisão (CHUZI S, et al, 2019;HEIDENREICH P, et al, 2022). As variáveis que devem ser analisadas são os fatores clínicos, econômicos e sociais.…”

“…Centro Universitário de Votuporanga (UNIFEV), São Paulo -SP 2. Universidade Nove de Julho campus Bauru (UNINOVE BAURU), Bauru -SP 3.…”

Modification of Cardiovascular Drugs in Advanced Heart Failure: A Narrative Review

“…Ambulatory inotropes are an option in some patients that is increasingly offered as a palliative therapy. Although there remains a profound lack of data and guidance on the effect of palliative inotropes on quality of life, limited available data suggest that inotrope therapy improves functional class and does not impact survival ( 12 ). Levosimendan has shown some advantages: for instance, its effects are sustained after the initial infusion, it can be used in patients treated with beta-blockers, and it does not increase oxygen requirements ( 13 ).…”

Benefits and Harms of Continuous Intravenous Inotropic Support as Palliative Therapy: A Single-Institution, Retrospective Analysis

“…5 CIIS has been shown to improve New York Heart Association (NYHA) functional class and health-related quality of life when compared to patients receiving usual HF care. 6,7 Though studies examining impact on survival are limited, heterogeneous in their inclusion and exclusion criteria, and of variable design, overall survival is not significantly different for patients on inotropes compared to controls. 6 One important caveat to the survival result reported in the meta-analysis by Nizamic and colleagues is that very few studies on inotropes included patients with a low cardiac output/index.…”

“…6,9 Among the 4000 patients per year who are treated with CIIS, around two thirds receive CIIS as palliative therapy; the intention of therapy is to palliate symptoms related to endstage HF, without expectation of life-prolongation or cure. 7,10 CIIS may be considered when patients have refractory symptoms (particularly, dyspnea at rest or exertional dyspnea and fatigue) despite maximal palliative therapies such as diuretics, nitrates, opioids, benzodiazepines, and oxygen. 11 Patients on CIIS as palliative therapy have a prognosis of around 6 months, on average, though with a large standard deviation of 6.6 months, suggestive of significant variability in treatment response.…”