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Meta-Analysis
. 2018 Sep;6(9):757-767.
doi: 10.1016/j.jchf.2018.03.019. Epub 2018 Jul 11.

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

Tiana Nizamic  1 , M Hassan Murad  2 , Larry A Allen  3 , Colleen K McIlvennan  3 , Sara E Wordingham  4 , Daniel D Matlock  5 , Shannon M Dunlay  6
Affiliations
Meta-Analysis

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

Tiana Nizamic et al. JACC Heart Fail. 2018 Sep.

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.

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Figures

Figure 1
Figure 1
Flow Diagram of Identification of Studies for Inclusion
Figure 2
Figure 2. Risk of Death in Patients Treated with Inotropes Compared with Controls
The pooled relative risk of death in patients treated with inotropes compared with controls in RCTs is shown.
Figure 3
Figure 3. Rate of All-Cause Hospitalization in Patients Treated with Inotropes
The rate of all-cause hospitalization per 100 person-months of follow-up in studies of patients treated with ambulatory inotropes is shown.
Figure 4
Figure 4. Changes in New York Heart Association Functional Class on Inotropes
4A. Studies comparing NYHA functional class before and while on inotropes Change in NYHA functional class in patients before and during use of inotropes in studies is shown. Drakos (Online ref.16), Roffman (27), and Tsagalou 2006 (Online ref.63) excluded as patient populations overlap. WMD= weighted mean difference 4B. Randomized trials comparing NYHA functional class on inotropes compared with controls The difference in NYHA functional class in patients receiving inotropes compared with controls in RCTs is shown. WMD= weighted mean difference
Figure 4
Figure 4. Changes in New York Heart Association Functional Class on Inotropes
4A. Studies comparing NYHA functional class before and while on inotropes Change in NYHA functional class in patients before and during use of inotropes in studies is shown. Drakos (Online ref.16), Roffman (27), and Tsagalou 2006 (Online ref.63) excluded as patient populations overlap. WMD= weighted mean difference 4B. Randomized trials comparing NYHA functional class on inotropes compared with controls The difference in NYHA functional class in patients receiving inotropes compared with controls in RCTs is shown. WMD= weighted mean difference
Figure 5
Figure 5
Expected Outcomes in Patients on Ambulatory Inotropes
See this image and copyright information in PMC

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References

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