“There is little evidence to guide how to select patients and administer this therapy,” Dr. Sarah Chuzi from Northwestern University, in Chicago, told Reuters Health by email. “We hope that our review will not only serve as a call to arms for more research in this area, but also provide some guidance to physicians who are navigating these difficult decisions and discussions with their patients.”
Ambulatory IV inotropic support is increasingly used as palliative therapy in patients with end-stage heart failure. Early studies showed benefits on hemodynamics and symptoms in patients with advanced heart failure with reduced ejection fraction (HFrEF), while some more-recent studies found decreased survival and/or increased adverse cardiovascular events linked to the treatment.
In their review, online July 3 in JAMA Cardiology, Dr. Chuzi and colleagues sought to provide guidance to clinicians on initiation, selection, maintenance and weaning or withdrawal of chronic inotropes and the management of concurrent therapies.
Identifying which patients might benefit from palliative inotropes can be difficult, according to the team. Patients and clinicians should consider clinical factors (heart failure stage, symptomatology and patient comfort while receiving inotropic support), as well as social and economic factors (caregiver availability, ability to maintain follow-up, concordance with patient goals and outpatient and hospice agency coverage of inotropes).
Patients and physicians should also discuss what is known about the risks and benefits of outpatient inotrope therapy in the context of the patient’s goals when determining whether to proceed with this therapy, the authors say.
Potential benefits include improved hemodynamics, quality of life, functional status, and heart failure symptoms. Potential risks include central-catheter complications, infectious complications, financial and caregiver burden and persistent heart failure symptoms.
Palliative therapy is just that: recent evidence suggests neutral effects on mortality and hospitalization rates, according to the review. Patient-specific factors should guide the choice of inotropic agent, but regardless of the inotrope selected, the goal should be to maintain the lowest effective dose necessary to improve hemodynamics and symptoms.
Specialty palliative-care consultation is strongly recommended, and regular follow-up with either the heart failure team or the palliative care team is critical.
“Heart failure patients who have very advanced disease and are either not candidates for other advanced surgical options like heart transplantation or do not desire those treatments can be candidates for palliative inotropes,” co-author Dr. Haider J. Warraich from Duke University School of Medicine, in Durham, North Carolina, told Reuters Health by email. “Even of these patients, not all will experience a benefit, which should really be in how well they feel and can perform routine activities.”
“This is a burdensome therapy that requires a lot of care since patients have an IV drip constantly going,” he said. “If patients or their caregivers are unable to maintain or care for this apparatus, they should not be receiving this therapy. Many patients also have adverse reactions to the medications, most commonly abnormal heart rhythms, and these patients too should not get this therapy. Finally, if patients are started on this medication and they don’t feel better, it may not be useful for them to be maintained on palliative inotropes.”
“The decision to pursue this therapy should be the result of a shared decision-making discussion between the patient, patient’s family members or caregivers, and the physician,” Dr. Chuzi said. “It can be difficult to have a discussion about the decision to pursue this therapy because these patients have advanced, end-stage disease and therefore the conversation requires a discussion of end-of-life goals and preferences.”
“Too often, patients are given a false impression that these are ‘life-saving medications’ or ‘rocket fuel’ for the heart,” she said. “In fact, there is no evidence that these medications extend life and therefore patients should understand the risks and expected benefits before initiating this therapy.”
Dr. Jane MacIver from University Health Network, in Toronto, Canada, who recently reviewed palliative approaches for heart failure end-of-life care, told Reuters Health by email, “My comment to MDs who may read this and not have a heart-failure background is that the burden of dying at home is significant. The number of caregiver hours involved would be high, heavy, and can be quite scary. Patients may die suddenly and unexpectedly with or without an ICD (implantable cardioverter defibrillator). This can be quite traumatic for family – especially if the ICD fires repeatedly. It isn’t (always) the good death you see in the movies. We need to better understand the caregiving experience.”
“I agree that for certain patients and their families (inotrope therapy) can allow them to be at home (and) improve symptoms and their quality of life,” she said. “We just need to make sure they are appropriately supported in their community.”
JAMA Cardiol 2019.