The use of positive inotropes in end-of-life heart failure care

Nauman, Deirdre

doi:10.1007/s11897-007-0035-0

Cited by 8 publications

(4 citation statements)

References 26 publications

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“…1 Inotropic agents may also be indicated as bridge to heart transplant or mechanical assist device implantation or as palliation for symptoms in end-stage HF. 17 These indications are in agreement with the European Society of Cardiology guidelines, which state that inotropic agents are indicated for patients with low SBP or a low measured cardiac index in the presence of signs of hypoperfusion or congestion. They also state that inotropic agents should be reserved for patients with dilated, hypokinetic ventricles and, when indicated, should be administered as early as possible and discontinued as soon as organ perfusion is restored and/or congestion is reduced.…”

Section: Inotropic Therapy In Current Guidelinessupporting

confidence: 81%

Old and New Intravenous Inotropic Agents in the Treatment of Advanced Heart Failure

Metra

Bettari

Carubelli

et al. 2011

Progress in Cardiovascular Diseases

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Inotropic agents are administered to improve cardiac output and peripheral perfusion in patients with systolic dysfunction and low cardiac output. However, there is evidence of increased mortality and adverse effects associated with current inotropic agents. These adverse outcomes may be ascribed to patient selection, increased myocardial energy expenditure and oxygen consumption, or to specific mechanisms of action. Both sympathomimetic amines and type III phosphodiesterase inhibitors act through an increase in intracellular cyclic adenosine monophoshate and free calcium concentrations, mechanisms that increase oxygen consumption and favor arrhythmias. Concomitant peripheral vasodilation with some agents (phosphodiesterase inhibitors and levosimendan) may also lower coronary perfusion pressure and favor myocardial damage. New agents with different mechanisms of action might have a better benefit to risk ratio and allow an improvement in tissue and end-organ perfusion with less untoward effects. We have summarized the characteristics of the main inotropic agents for heart failure treatment, the data from randomized controlled trials, and future perspectives for this class of drugs. (Prog Cardiovasc Dis 2011;54:97-106)

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Section: Inotropic Therapy In Current Guidelinessupporting

confidence: 81%

Old and New Intravenous Inotropic Agents in the Treatment of Advanced Heart Failure

Metra

Bettari

Carubelli

et al. 2011

Progress in Cardiovascular Diseases

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“…18,19 For some patients with end-stage HF, quality of life may be more important than quantity of life, and inotropes can be used for palliative care. 20 In light of the existing evidence, the 2013 guidelines from American College of Cardiology/American Heart Association recommend temporary intravenous inotropes for patients with cardiogenic shock until definite therapy or resolution of the precipitating problem (class I, level of evidence C), as a bridge to transplant or LVAD in candidates with refractory symptoms on oral and device therapy (class IIa, level of evidence C), and state that inotropes can be considered for palliative therapy or in hospitalized patients with low output state (class IIb, level of evidence B). 21 In our study, with contemporary HF management, patients who had inotrope-dependent advanced HF but were not candidates for heart transplant or LVAD had a median survival of 9 months.…”

Section: Discussionmentioning

confidence: 99%

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

Hashim

Sanam

Revilla-Martinez

et al. 2015

Circ: Heart Failure

115

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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. (Circ Heart Fail.

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“…3,4 It is associated with recurrent hospitalisation for HF exacerbations 2 and the need for intravenous vasoactive treatment that becomes increasingly frequent. [5][6][7] In our prior publication, we found high mortality mirroring that of western fi gures among unselect cohort of HF patients. 8 In end-stage HF not eligible for heart transplantation or destination mechanical assist device, palliative care complementing a chronic disease management programme serves to optimise symptom controls and address multiple domains of patient and family distress, [9][10][11] albeit some defi ciencies in hard clinical evidence.…”

Section: Introductionmentioning

confidence: 64%

Home-Based Advance Care Programme is Effective in Reducing Hospitalisations of Advanced Heart Failure Patients: A Clinical and Healthcare Cost Study

Wong

Tan

Seow

et al. 2013

Ann Acad Med Singap

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Introduction: In end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients. Materials and Methods: Prospectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year. Results: Forty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively. Conclusion: Home-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well. Key words: Palliative care, End-stage heart failure

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The use of positive inotropes in end-of-life heart failure care

Cited by 8 publications

References 26 publications

Old and New Intravenous Inotropic Agents in the Treatment of Advanced Heart Failure

Old and New Intravenous Inotropic Agents in the Treatment of Advanced Heart Failure

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

Home-Based Advance Care Programme is Effective in Reducing Hospitalisations of Advanced Heart Failure Patients: A Clinical and Healthcare Cost Study

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