Ambulatory Inotrope Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis

Tiana Nizamic, Mohammad H Murad, Larry A. Allen, Colleen K. McIlvennan, Sara E. Wordingham, Daniel D. Matlock, Shannon M Dunlay

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
JournalJACC: Heart Failure
DOIs
StateAccepted/In press - Jan 1 2018

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Meta-Analysis
Heart Failure
Confidence Intervals
Mortality
Implantable Defibrillators
MEDLINE
Observational Studies
Shock
Hospitalization
Outpatients
Randomized Controlled Trials
Odds Ratio
Transplants
Survival
Therapeutics
Infection

Keywords

  • death
  • hospitalization
  • palliative care
  • risk
  • transplant

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Ambulatory Inotrope Infusions in Advanced Heart Failure : A Systematic Review and Meta-Analysis. / Nizamic, Tiana; Murad, Mohammad H; Allen, Larry A.; McIlvennan, Colleen K.; Wordingham, Sara E.; Matlock, Daniel D.; Dunlay, Shannon M.

In: JACC: Heart Failure, 01.01.2018.

Research output: Contribution to journalArticle

Nizamic, Tiana ; Murad, Mohammad H ; Allen, Larry A. ; McIlvennan, Colleen K. ; Wordingham, Sara E. ; Matlock, Daniel D. ; Dunlay, Shannon M. / Ambulatory Inotrope Infusions in Advanced Heart Failure : A Systematic Review and Meta-Analysis. In: JACC: Heart Failure. 2018.
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abstract = "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.",
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