@article{19ffc35906df4af09d6e047ccb7f56c0,
title = "Ambulatory Inotrope Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis",
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.",
keywords = "death, hospitalization, palliative care, risk, transplant",
author = "Tiana Nizamic and Murad, {M. Hassan} and Allen, {Larry A.} and McIlvennan, {Colleen K.} and Wordingham, {Sara E.} and Matlock, {Daniel D.} and Dunlay, {Shannon M.}",
note = "Funding Information: Dr. Dunlay{\textquoteright}s contribution was supported by U.S. National Institutes of Health grant K23 HL 116643. Dr. Allen has financial relationships with Boston Scientific, Cytokinetics, Novartis, Patient-Centered Outcomes Research Institute (PCORI), National Institutes of Health, and the American Heart Association. Dr. Matlock has received support from the American College of Cardiology Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Funding Information: There were several important findings from this systematic review. First, the quality of data assessing the risks and benefits of ambulatory intravenous inotropes, even among RCTs, is limited, which warrants careful consideration when interpreting results. Second, most studies were small, and thus, estimates are plagued by wide confidence intervals. Third, data for inotropes as palliative therapy are particularly lacking, which limited our ability to summarize comparative risks and benefits in most patients with advanced HF who are not eligible for mechanical circulatory support or transplantation. However, based upon available evidence, inotrope infusions appear to improve NYHA functional class. Limited evidence suggests inotropes do not increase the risk of death. Although hospitalizations and ventricular arrhythmias are common, there is insufficient evidence to conclude whether inotropes affect the risk of these events. Finally, outpatient inotrope infusions are relatively expensive, and although they appear to be cost-saving compared with ongoing hospitalization in a BTT population, it is unclear whether they are cost-effective as palliative therapy. Publisher Copyright: {\textcopyright} 2018 American College of Cardiology Foundation",
year = "2018",
month = sep,
doi = "10.1016/j.jchf.2018.03.019",
language = "English (US)",
volume = "6",
pages = "757--767",
journal = "JACC: Heart Failure",
issn = "2213-1779",
publisher = "Elsevier BV",
number = "9",
}