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Maini M, Anderson KM, Seplowe M, Crowell NA, Pitcher C, Scally R, Weintraub WS, Najjar SS, Groninger H, Rao A. Disease-State Understanding and Experience of Patients Receiving Continuous Intravenous Inotropic Support as Palliative Therapy: A Multicenter Survey. J Palliat Med 2024; 27:1026-1032. [PMID: 38564223 DOI: 10.1089/jpm.2023.0670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background: The use of continuous intravenous inotropic support (CIIS) as palliative therapy in patients with advanced heart failure (HF) has increased over the past decade. CIIS improves New York Heart Association (NYHA) functional class but does not impact survival. Objective: The objective of this study was to examine patients' understanding of the therapeutic intent of CIIS, prognostic awareness, and quality of life with CIIS. Design: We conducted a prospective, cross-sectional, multicenter study of patients with advanced HF receiving CIIS as palliative therapy between 2020 and 2022. Settings/Subjects: An investigator-developed survey instrument was administered to outpatients on CIIS in the United States via telephone. Measurements: Survey data were analyzed using descriptive and inferential statistics. Results: Forty-eight patients, 63% male, 81% African American/Black, with a mean age of 68.9 (standard deviation 12.3) years, participated in this study. The majority of patients responded that they expected CIIS to make them feel better (79%) and increase longevity (75%), but few expected that CIIS would cure their HF (19%). Patients described their overall quality of life on CIIS as not better/worse (19%), somewhat better (46%), and significantly better (35%) and reported high treatment satisfaction (87% were at least somewhat satisfied). Conclusions: In this study, patients report improved quality of life with CIIS as palliative therapy. Patients on CIIS as palliative therapy expected increased survival on CIIS, which is incongruent with current evidence. Further studies on how we can improve care processes so that patients have accurate prognostic and disease-state awareness, and receive goal concordant care, are warranted.
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Affiliation(s)
- Mansi Maini
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Kelley M Anderson
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - Matthew Seplowe
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Nancy A Crowell
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - Clark Pitcher
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Scally
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - William S Weintraub
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samer S Najjar
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hunter Groninger
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Anirudh Rao
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
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Cox ZL, Dalia T, Goyal A, Fritzlen J, Gupta B, Shah Z, Sauer AJ, Haglund NA. Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 Study. J Card Fail 2024; 30:329-336. [PMID: 37871843 DOI: 10.1016/j.cardfail.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. METHODS We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. RESULTS A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17-66) ng/mL and a median peak concentration of 207 (134-293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%-65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2-2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. CONCLUSIONS In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice and Pharmaceutical Science, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Tarun Dalia
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Amandeep Goyal
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - John Fritzlen
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Bhanu Gupta
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Zubair Shah
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Nicholas A Haglund
- Minneapolis Heart Institute, Allina Health at Abbott Northwestern Hospital, Minneapolis, MN
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Silva EVC, Ochiai ME, Vieira KRN, Pereira Barretto AC. The use of peripherally inserted central catheter reduced the incidence of phlebitis in heart failure patients: A randomized trial. J Vasc Access 2023; 24:942-947. [PMID: 34812074 DOI: 10.1177/11297298211059650] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND During decompensated heart failure, the use of intravenous inotropes can be necessary. With peripheral venous access, prolonged inotrope infusion can cause phlebitis. However, traditional central venous catheters have possible complications. Peripherally inserted central catheters (PICCs) may be an alternative to traditional catheters. AIM Our objective was to compare the incidence of phlebitis between patients with PICC and those with peripheral venous access catheter indwelling. METHODS In a randomized clinical trial, the patients were randomized to PICC and control groups, with 40 patients in each group. The inclusion criteria were hospitalized patients with advanced heart failure, ejection fraction of <0.45, and platelet count of >50,000/mm3 and current use of continuous intravenous infusion of dobutamine. The patients were randomly assigned to receive a PICC or keep their peripheral venous access. The primary end point was the occurrence of phlebitis. RESULTS The PICC and control groups included 40 patients each. The median age was 61.5 years; ejection fraction, 0.24; and dobutamine dose, 7.73 µg/(kg min). Phlebitis occurred in 1 patient (2.5%) in the PICC group and in 38 patients (95.0%) in the control group, with an odds ratio of 0.10% (95% confidence interval: 0.01%-1.60%, p < 0.001). CONCLUSION In conclusion, in severe heart failure patients who received intravenous dobutamine, PICC use reduced the incidence of phlebitis when compared to patients with peripheral venous access. Therefore, the PICC use should considered over peripheral venous access for prolonged intravenous therapy in heart failure patients.
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Puri A, Dai H, Giri M, Wu C, Huang H, Zhao Q. The incidence and risk of venous thromboembolism associated with peripherally inserted central venous catheters in hospitalized patients: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:917572. [PMID: 35958406 PMCID: PMC9360324 DOI: 10.3389/fcvm.2022.917572] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background Venous thromboembolism (VTE) can be fatal if not treated promptly, and individual studies have reported wide variability in rates of VTE associated with peripherally inserted central catheters (PICC). We thus conducted this meta-analysis to investigate the overall incidence and risk of developing PICC-related VTE in hospitalized patients. Methods We searched PubMed, Embase, Scopus, and Web of Science databases from inception until January 26, 2022. In studies with a non-comparison arm, the pooled incidence of PICC-related VTE was calculated. The pooled odds ratio (OR) was calculated to assess the risk of VTE in the studies that compared PICC to the central venous catheter (CVC). The Newcastle-Ottawa Scale was used to assess methodological quality. Results A total of 75 articles (58 without a comparison arm and 17 with), including 109292 patients, were included in the meta-analysis. The overall pooled incidence of symptomatic VTE was 3.7% (95% CI: 3.1–4.4) in non-comparative studies. In the subgroup meta-analysis, the incidence of VTE was highest in patients who were in a critical care setting (10.6%; 95% CI: 5.0–17.7). Meta-analysis of comparative studies revealed that PICC was associated with a statistically significant increase in the odds of VTE events compared with CVC (OR, 2.48; 95% CI, 1.83–3.37; P < 0.01). However, in subgroup analysis stratified by the study design, there was no significant difference in VTE events between the PICC and CVC in randomized controlled trials (OR, 2.28; 95% CI, 0.77–6.74; P = 0.13). Conclusion Best practice standards such as PICC tip verification and VTE prophylaxis can help reduce the incidence and risk of PICC-related VTE. The risk-benefit of inserting PICC should be carefully weighed, especially in critically ill patients. Cautious interpretation of our results is important owing to substantial heterogeneity among the studies included in this study.
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Affiliation(s)
- Anju Puri
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyun Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mohan Giri
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengfei Wu
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanhuan Huang
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinghua Zhao
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Qinghua Zhao,
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McPherson A, Nguyen C, Groninger H, Anderson KM, Henderson P, Rao A. Continuous Intravenous Inotropic Support for Advanced Heart Failure: Palliative Considerations. J Pain Palliat Care Pharmacother 2022; 36:59-67. [PMID: 35319327 DOI: 10.1080/15360288.2022.2050456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Pulmonary artery catheter epidemiology of risk in pre-heart-transplant recipients. Infect Control Hosp Epidemiol 2019; 40:632-638. [PMID: 31038098 DOI: 10.1017/ice.2019.94] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Central-line-associated bloodstream infections (CLABSIs) are a known complication of central venous access. Pulmonary artery catheters (PAC) are frequently used in pre-heart-transplant patients, but the rate of CLABSI in this population is unknown. We sought to estimate the rate of CLABSI and identify factors associated with development of infection in patients actively listed for heart transplantation with a PAC. DESIGN Retrospective cohort study. SETTING This study was conducted in 3 intensive care units at an academic tertiary-care center in Minnesota. PATIENTS 61 pre-heart-transplant patients in an intensive care unit with a PAC in place from January 2013 to December 2016, totaling 219 PACs. METHODS At-risk patients, pertinent risk factors, and demographic data were obtained using Mayo Clinic's Unified Data Platform. CLABSIs were identified through internal infection prevention and control data. Characteristics of PAC use and infection rate were collected and analyzed using Kaplan-Meier estimates and time-dependent Cox models. RESULTS Among pre-heart-transplant patients with a PAC, there were 14 CLABSIs, for an infection rate of 5.46 of 1,000 PAC days (95% confidence interval [CI], 2.98-9.15). The most common causative organism was coagulase-negative Staphylococcus (79%). In unadjusted analyses, CLABSI was associated with shorter time to transplant (hazard ratio [HR], 2.49; P = .027), but not mortality (HR, 1.79; P = .355). CONCLUSIONS The rate of CLABSI with PAC is high. Prolonged PAC use in the pre-heart-transplant population should be revisited.
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Nizamic T, Murad MH, Allen LA, McIlvennan CK, Wordingham SE, Matlock DD, Dunlay SM. Ambulatory Inotrope Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis. JACC-HEART FAILURE 2018; 6:757-767. [PMID: 30007556 DOI: 10.1016/j.jchf.2018.03.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study sought to systematically review the available evidence of risks and benefits of ambulatory intravenous inotrope therapy in advanced heart failure (HF). BACKGROUND Ambulatory inotrope infusions are sometimes offered to patients with advanced Stage D HF; however, an understanding of the relative risks and benefits is lacking. METHODS On August 7, 2016, we searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for studies of long-term use of intravenous inotropes in outpatients with advanced HF. Meta-analysis was performed using random effects models. RESULTS A total of 66 studies (13 randomized controlled trials and 53 observational studies) met inclusion criteria. Most studies were small and at high risk for bias. Pooled rates of death (41 studies), all-cause hospitalization (15 studies), central line infection (13 studies), and implantable cardioverter-defibrillator shocks (3 studies) of inotropes were 4.2, 22.2, 3.6, and 2.4 per 100 person-months follow-up, respectively. Improvement in New York Heart Association (NYHA) functional class was greater in patients taking inotropes than in controls (mean difference of 0.60 NYHA functional classes; 95% confidence interval [CI]: 0.22 to 0.98; p = 0.001; 5 trials). There was no significant difference in mortality risk in those taking inotropes compared with controls (pooled risk ratio: 0.68; 95% CI: 0.40 to 1.17; p = 0.16; 9 trials). Data were too limited to pool for other outcomes or to stratify by indication (i.e., bridge-to-transplant or palliative). CONCLUSIONS High-quality evidence for the risks and benefits of ambulatory inotrope infusions in advanced HF is limited, particularly when used for palliation. Available data suggest that inotrope therapy improves NYHA functional class and does not impact survival.
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Affiliation(s)
- Tiana Nizamic
- Department of Medicine, University of Colorado at Denver, Denver, Colorado
| | - M Hassan Murad
- Division of Preventive, Occupational, and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado, Denver, Colorado
| | - Colleen K McIlvennan
- Division of Cardiology, Department of Medicine, University of Colorado, Denver, Colorado
| | - Sara E Wordingham
- Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado at Denver, Denver, Colorado
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection. J Heart Lung Transplant 2017; 36:1137-1153. [DOI: 10.1016/j.healun.2017.06.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022] Open
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Acharya D, Sanam K, Revilla-Martinez M, Hashim T, Morgan CJ, Pamboukian SV, Loyaga-Rendon RY, Tallaj JA. Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy. Am J Cardiol 2016; 117:952-6. [PMID: 26810859 DOI: 10.1016/j.amjcard.2015.12.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
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 cardioverter-defibrillator 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 cardioverter-defibrillator 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.
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12
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Greene MT, Flanders SA, Woller SC, Bernstein SJ, Chopra V. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities. Am J Med 2015; 128:986-93.e1. [PMID: 25940453 DOI: 10.1016/j.amjmed.2015.03.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peripherally inserted central catheters are associated with upper-extremity deep vein thrombosis. Whether they also are associated with lower-extremity deep vein thrombosis or pulmonary embolism is unknown. We examined the risk of venous thromboembolism in deep veins of the arm, leg, and chest after peripherally inserted central catheter placement. METHODS We conducted a multicenter, retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. Peripherally inserted central catheter presence, comorbidities, venous thrombosis risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazards models were fit to examine the association between peripherally inserted central catheter placement and 90-day hazard of upper- and lower-extremity deep vein thrombosis or pulmonary embolism, adjusting for patient-level characteristics and natural clustering within hospitals. RESULTS A total of 3790 patients received a peripherally inserted central catheter during hospitalization. From hospital admission to 90 days, 876 thromboembolic events (208 upper-extremity deep vein thromboses, 372 lower-extremity deep vein thromboses, and 296 pulmonary emboli) were identified. After risk adjustment, peripherally inserted central catheter use was independently associated with all-cause venous thromboembolism (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper-extremity deep vein thrombosis (HR, 10.49; 95% CI, 7.79-14.11), and lower-extremity deep vein thrombosis (HR, 1.48; 95% CI, 1.02-2.15). Peripherally inserted central catheter use was not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization. CONCLUSIONS Peripherally inserted central catheter use is associated with upper- and lower-extremity deep vein thrombosis. Weighing the thrombotic risks conferred by peripherally inserted central catheters against clinical benefits seems necessary.
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Affiliation(s)
- M Todd Greene
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Mich; Department of Internal Medicine, Division of General Medicine, University of Michigan School of Medicine, Ann Arbor, Mich; VA Ann Arbor Health Care System, Ann Arbor, Mich
| | - Scott A Flanders
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Mich; Department of Internal Medicine, Division of General Medicine, University of Michigan School of Medicine, Ann Arbor, Mich
| | - Scott C Woller
- Intermountain Medical Center, Murray, Utah; University of Utah School of Medicine, Salt Lake City, Utah
| | - Steven J Bernstein
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Mich; Department of Internal Medicine, Division of General Medicine, University of Michigan School of Medicine, Ann Arbor, Mich; VA Ann Arbor Health Care System, Ann Arbor, Mich
| | - Vineet Chopra
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Mich; Department of Internal Medicine, Division of General Medicine, University of Michigan School of Medicine, Ann Arbor, Mich; VA Ann Arbor Health Care System, Ann Arbor, Mich.
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Gorodeski EZ, Kim A. Implications of central venous catheters in patients with stage D heart failure who are stable but inotrope dependent. J Card Fail 2014; 20:638-40. [PMID: 25058009 DOI: 10.1016/j.cardfail.2014.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Eiran Z Gorodeski
- Section of Heart Failure and Cardiac Transplantation, Tomsich Family Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Center for Connected Care, Cleveland Clinic, Cleveland, Ohio.
| | - Alice Kim
- Center for Connected Care, Cleveland Clinic, Cleveland, Ohio; Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
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