Outcomes In Patients On Chronic Inotropic Support Who Are Not Candidates For Advanced Heart Failure Therapies

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Introduction Significant therapeutic advancements including guideline-directed-therapy (GDMT) and device implantation have improved outcomes in heart failure patients. Their impact on patients with advanced heart failure requiring chronic inotropic support who are not candidates for left ventricular assist device (LVAD) or heart transplant (HT) is not well studied. We aimed to study outcomes in these patients discharged on inotropes while comparing the dobutamine and milrinone cohorts. Methods We conducted a retrospective multi-center study from Jan 2015 to May 2019. A total of 249 patients who were hospitalized with refractory stage-D heart failure and discharged on continuous long-term milrinone or dobutamine therapy were included. Patients who were candidates for HT or LVAD and those discharged on comfort measures were excluded. Multivariable logistic regression was utilized to assess odds of mortality in these patients. Results Overall mean age was 64.8 ±13.4 years. Majority of the patients were males, Caucasian and had a pre-implanted cardiac device. Common comorbidities included CAD, diabetes, hypertension and CKD. Age and baseline comorbidities were similar in both groups except for CKD which was more prevalent in dobutamine group (59.4 vs 52.0; p-value=0.02). Overall, mean baseline Ejection Fraction was 20.2%, similar in both groups (p=0.71). Patients on dobutamine had higher baseline cardiac indices than milrinone group (Fick 2.0 vs 1.8; p-value=0.048, Thermodilution 2.0 vs 1.6; p-value=0.002). Overall, 1-year mortality was 70.7 %. Patients on milrinone had lower 1-year-mortality compared to dobutamine group (58.1% vs 85.0%; P-value<0.01). Unadjusted odds ratio (OR) for milrinone group was 0.24 (CI 0.13-0.46, p-value=p<0.001). When adjusted for age, sex, race and BMI, OR was 0.29 (CI 0.15-0.58, p-value=0.001). Milrinone cohort had more patients discharged on beta blocker (42.9 vs 8.6; p-value <0.001). Other GDMT was also more common on discharge in milrinone group, though statistical significance was not reached. Six patients became candidates for advanced therapies (LVAD/HT). (See Table) Conclusion Mortality remains high in patients started on chronic inotropes who are not candidates for LVAD/HT. Milrinone may have better patient outcomes as compared to dobutamine but larger comparative controlled studies are needed to confirm this. Significant therapeutic advancements including guideline-directed-therapy (GDMT) and device implantation have improved outcomes in heart failure patients. Their impact on patients with advanced heart failure requiring chronic inotropic support who are not candidates for left ventricular assist device (LVAD) or heart transplant (HT) is not well studied. We aimed to study outcomes in these patients discharged on inotropes while comparing the dobutamine and milrinone cohorts. We conducted a retrospective multi-center study from Jan 2015 to May 2019. A total of 249 patients who were hospitalized with refractory stage-D heart failure and discharged on continuous long-term milrinone or dobutamine therapy were included. Patients who were candidates for HT or LVAD and those discharged on comfort measures were excluded. Multivariable logistic regression was utilized to assess odds of mortality in these patients. Overall mean age was 64.8 ±13.4 years. Majority of the patients were males, Caucasian and had a pre-implanted cardiac device. Common comorbidities included CAD, diabetes, hypertension and CKD. Age and baseline comorbidities were similar in both groups except for CKD which was more prevalent in dobutamine group (59.4 vs 52.0; p-value=0.02). Overall, mean baseline Ejection Fraction was 20.2%, similar in both groups (p=0.71). Patients on dobutamine had higher baseline cardiac indices than milrinone group (Fick 2.0 vs 1.8; p-value=0.048, Thermodilution 2.0 vs 1.6; p-value=0.002). Overall, 1-year mortality was 70.7 %. Patients on milrinone had lower 1-year-mortality compared to dobutamine group (58.1% vs 85.0%; P-value<0.01). Unadjusted odds ratio (OR) for milrinone group was 0.24 (CI 0.13-0.46, p-value=p<0.001). When adjusted for age, sex, race and BMI, OR was 0.29 (CI 0.15-0.58, p-value=0.001). Milrinone cohort had more patients discharged on beta blocker (42.9 vs 8.6; p-value <0.001). Other GDMT was also more common on discharge in milrinone group, though statistical significance was not reached. Six patients became candidates for advanced therapies (LVAD/HT). (See Table) Mortality remains high in patients started on chronic inotropes who are not candidates for LVAD/HT. Milrinone may have better patient outcomes as compared to dobutamine but larger comparative controlled studies are needed to confirm this.