Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy Deepak Acharya, MD, MSPHa,*, Kumar Sanam, MDb, Marina Revilla-Martinez, MDc, Taimoor Hashim, MDa, Charity J. Morgan, PhDd, Salpy V. Pamboukian, MD, MSPHa, Renzo Y. Loyaga-Rendon, MD, PhDa, and Jose A. Tallaj, MDa Inotropes improve symptoms in advanced heart failure (HF) but were associated with higher mortality in clinical trials. Recurrent hospitalizations, arrhythmias, and infections contribute to morbidity and mortality, but the risks of these complications with modern HF therapies are not well known. We collected arrhythmia, infection, and hospitalization data on 197 patients discharged from our institution from January 2007 to March 2013 on intravenous inotropes. Patients were followed until they died, received a transplant or left ventricular assist device, were weaned off inotropes, or remained on inotropes at the end of the study. All patients had stage D HF. At baseline, 30% had a history of ventricular tachycardia, 7.1% had a history of cardiac arrest, and 39% had a history of atrial fibrillation. During follow-up, 33 patients (17%) had one or more implantable cardioverteredefibrillator shocks. Of patients who had shocks, 27 patients (82%) had appropriate shocks for ventricular tachycardia/ventricular fibrillation, 3 patients (9%) had inappropriate shocks, and 3 patients (9%) had both appropriate and inappropriate shocks. The risk of implantable cardioverteredefibrillator shock was not related to dose of inotrope (p [ 0.605). Fifty-seven patients (29%) had one or more infections during follow-up. Bacteremia was the most common type of infection. Implanted electrophysiology devices did not confer an increased risk of infection. One hundred twelve patients (57%) had one or more hospitalizations during follow-up. Common causes of hospitalizations were worsening HF symptoms (41%), infections (20%), and arrhythmias (12%). In conclusion, arrhythmias, infections, and rehospitalizations are important complications of inotropic therapy. Ó 2016 Elsevier Inc. All rights reserved. (Am J Cardiol 2016;-:-e-) Inotropic agents have been studied for several decades in heart failure (HF). The early studies showed improvement in hemodynamic profiles. Larger studies such as Prospective Randomized Milrinone Survival Evaluation Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (PROMISE OPTIME-CHF), and the Acute Decompensated Heart Failure National Registry (ADHERE) registry raised concerns about higher mortality with inotrope use and showed that hemodynamic improvement does not necessarily translate into survival benefit.1e4 Inotropes are therefore not currently used routinely for acute decompensated HF. The general role of inotropes in current practice is to treat cardiogenic shock and low output states, improve symptoms, optimize hemodynamics, and maintain end-organ function in transplant or left ventricular

assist device (LVAD) candidates,5 or as palliative therapy. Several of the inotrope trials were performed before widespread use of b blockers, aldosterone antagonists, and implantable cardioverteredefibrillators (ICDs) for primary prevention in HF. These treatments used concomitantly with inotropes may impact the risks and complications associated with inotropes.6 Major issues related to inotrope therapy include infections related to chronic indwelling catheters, arrhythmias, and recurrent hospitalizations, and these have not been analyzed in detail in contemporary cohorts. A detailed examination of these complications would facilitate a more informed discussion with patients and families facing these choices and may identify strategies to decrease these complications and is the focus of this study. Methods

a

Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama; bDivision of Cardiovascular Diseases, St. John Providence Hospital, Detroit, Michigan; cDivision of Cardiovascular Disease, University Hospital at Valladolid, Valladolid, Spain; and d Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama. Manuscript received September 17, 2015; revised manuscript received and accepted December 16, 2015. This study was supported by grants from the University of Alabama at Birmingham, Birmingham, AL, Division of Cardiovascular Diseases. See page 4 for disclosure information. *Corresponding author: Tel: (205) 934-3438; fax: (205) 975-9320. E-mail address: [email protected] (D. Acharya). 0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.12.030

This study was a retrospective review of all adult patients with advanced HF discharged from one tertiary care institution on milrinone or dobutamine from January 2007 to March 2013. Patients on an inotrope were identified using multiple methods: review of our patient records for 3 of 5 home infusion companies that supplied inotropes during that period, review of the HF clinic charts, query of the hospital discharge, and clinic electronic medical records (EMRs) for patients prescribed dobutamine or milrinone, and review of patients who received LVAD or transplantation during that period. All patients had stage D HF, www.ajconline.org

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The American Journal of Cardiology (www.ajconline.org)

and were deemed inotropeedependent and managed by HF specialists. Exclusion criteria included patients who received inotropes after LVAD, patients who received inotropes in the hospital only, patients who received inotropes for congenital heart disease or isolated right ventricular failure, and patients aged