Patients with heart failure (HF) requiring advanced therapies (AT) or palliative inotropes have been well described in the literature, but less is known regarding their earlier clinical course. Patients started on inotropes may be appropriate candidates for AT, yet do not always receive timely evaluations. Given the high mortality associated with end stage HF, we investigated the clinical characteristics and outcomes of HF patients after initiation of inotrope therapy.
We retrospectively evaluated 3,948 patients with HF admitted to the University of Pittsburgh Medical Center’s 40 hospital network between 2010-2015 from the time of their first identified inotrope therapy to present. Patients post-cardiotomy or with prior heart transplant (HT) or ventricular assist device (VAD) were excluded.
The patients were predominantly male (61%), white (80%) with a mean age of 68 (±15). Common comorbidities included ventricular arrhythmia (9%), atrial fibrillation (21%) and CKD (59%). 13% had an ICD and 7% had biventricular pacing. Initial EF was reduced (32%±18). During hospitalization 38% were treated with milrinone, 52% with dobutamine and 10% had been on either. Overall, median survival was 6.2 months (95% CI 5.2-7.4). On index hospitalization 1,005 (26%) patients died, 83 (2%) received AT (13 HT and 70 VAD), 491 (12%) were discharged on home inotrope therapy (HI) and 2369 (60%) without HI. Excluding patients that received AT after discharge, Kaplan-Meier analysis showed significantly worse 1-year mortality in patients discharged with HI (51%) versus those without HI (41%) (p< 0.0001). Median survival was 4 months (95% CI 2.6-6.9) versus 21.8 months (95% CI 18.6-25) respectively. In patients discharged without HI, 540 (23%) were reinitiated on inotropes with a median time to reinitiation of 3.5 months (95% CI 2.6-4.0). Only 75 (3%) received AT and 1,604 (68%) died without receiving AT. Of patients dying without AT only 498 (31%) had outpatient cardiology follow-up within 6 months of discharge.
Most HF patients admitted for inotrope therapy were discharged without HI, with survival remaining low in this group. Patients discharged without HI have longer median survival time yet few go on to follow-up with outpatient cardiology or receive AT. This may represent an opportunity for earlier AT evaluation before further clinical deterioration.
Copyright © 2020. Published by Elsevier Inc.