Anticipated vs. Actual Outcomes of Elective Inotrope Initiation in Hemodynamically Stable Heart Failure Patients

Introduction The expectations and outcomes of elective inotropeuse as adjunctive therapy during heart failure (HF) hospitalization are not known. This prospective study aims to describe the intent and results of inotropictherapy initiated electively during HF hospitalization in hemodynamically stable patients. Methods We used a prospective, multi-center design in 6 academic medical centers of the Heart Failure Apprentice Network to collect data on hemodynamically stable patients started electively on inotropes. Patients were excluded if deemed to need immediate inotropictherapy for progressive hemodynamic deterioration or other critical care for cardiogenic shock. We prospectively recorded data when intravenous inotropictherapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed for events through hospital discharge, including documentation of advanced care planning. Baseline data from admission was collected retrospectively. Results A total of 93 patients were included and average age was 60 years and EF 24%±12%. At the time of inotropeinitiation, attending cardiologists thought 50% of patients had a “high or very high” likelihood of becoming inotropedependent and 58% had a “high” likelihood of death, transplant or durable ventricular assist deviceplacement within the next 6 months. Despite these expectations, only 51% of patients had goals of care conversations prior to inotropeinitiation. An additional 19% had it after inotropeinitiation but before discharge. The average duration of inotropetherapy was 11±12 days. Ultimately, 29% were discharged on inotropesand 26% died or entered hospice by the time of discharge. Provider predictions about the long term need for inotropesor death/hospice was accurate 51% of the time. Conclusions Over half of patients electively started on inotropeswith stable hemodynamics ultimately required home inotropes, died during admission or were discharged to hospice. Heart failure clinicians did not reliably identify those patients with inotropicdependence, death, or hospice by the time of discharge. In light of these poor outcomes and our limited ability to accurately predict them, goals of care discussions should be emphasized prior to inotropeinitiation.