Outcomes of Patients Receiving Inotropes for Palliative Indication versus as a Bridge to Surgical Therapy

Abstract

Introduction Use of long-term, continuous intravenous inotropic support (CIIS) has increased in prevalence over the past decade. Published evidence indicates that CIIS improves NYHA functional class but does not impact survival. Robust data regarding clinical outcomes of patients receiving inotropic support for palliative indication (i.e. not being considered for mechanical circulatory support (MCS) or orthotopic heart transplantation (OHT)) are lacking. Objective Describe the outcomes of patients receiving CIIS for palliative indication versus as a bridge to surgical therapy, including length of use, mortality, and referral to palliative care and/or hospice. Methods With institutional review board approval, we conducted a retrospective cohort study examining outcomes in patients discharged from an urban, tertiary-care, academic hospital on CIIS between 2010 and 2016. Patients were stratified by indication for initiation of inotropic support. Electronic health record review was conducted to abstract patient demographics, clinical characteristics, duration of inotrope use, reason for CIIS discontinuation, and composite end-point of hospice referral or death at the end of the study period. Results We identified 380 patients (24.7% female; 66% African American) who were discharged on CIIS during the study period. Average age of the study participants was 59.2 +/14.5 years. Thirty-two percent of patients had ischemic cardiomyopathy, 66% had nonischemic cardiomyopathy, 4% had mixed-etiology cardiomyopathy. All patients had stage D HFrEF, with mean ejection fraction of 19.4% +/- 4.5%. Of these, 129 patients (34%) were receiving CIIS for palliative indication, and the remaining 251 patients (66%) as a bridge to definitive surgical therapy (MCS or OHT). Of patients receiving CIIS for palliative indication, the mean length of use was 202 +/- 214 days, with a composite end-point of hospice referral or death occurring in n=122 (95%). The majority of patients receiving inotropes for palliative indication n=92 (71%) received a palliative care consult and were referred to hospice n=79 (61%). Of patients receiving CIIS as a bridge to surgical therapy, 151 (62.5%) received MCS/OHT and 51 (20.3%) died prior to receiving surgical therapy, with lower rates of referral to palliative care (n=24 or 47%) and hospice (n=13 or 25%). Conclusions In this large, racially diverse sample of patients, those receiving CIIS for palliative indication lived on average for about 6.5 months, though with a large variation between patients. Patients who are initiated on CIIS as bridge to surgical therapy have a high mortality while awaiting surgical therapy, but are less likely to receive palliative care and hospice services.