Beneficial effects of intermittent home administration of the inotrope/vasodilator milrinone in patients with end-stage congestive heart failure: a preliminary study

Comparative Effectiveness and Safety of Intermittent, Repeated, or Continuous Use of Levosimendan, Milrinone, or Dobutamine in Patients With Advanced Heart Failure: A Network and Single-Arm Meta-analysis

ABSTRACT

The aim of this study was to synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy among patients with advanced heart failure. We systematically searched the PubMed, Embase, and Cochrane Library electronic databases, with a cutoff date of November 23, 2023, for studies reporting outcomes in adult patients with advanced heart failure treated with intermittent, repeated, or continuous levosimendan, milrinone, or dobutamine. Forty-one studies (18 randomized controlled trials and 23 cohort studies) comprising 5137 patients met the inclusion criteria. The results of the network meta-analysis of randomized controlled trials showed that levosimendan had significant advantages over milrinone or dobutamine in reducing mortality and improving left ventricular ejection fraction. A single-arm meta-analysis also indicated that levosimendan had the lowest mortality and significantly improved B-type brain natriuretic peptide and left ventricular ejection fraction. Regarding safety, hypotension events were observed more frequently in the levosimendan and milrinone groups. However, the current evidence is limited by the heterogeneity and relatively small sample size of the studies.

Successful conservative management of left ventricular assist device candidates

AIMS

Clinical trials comparing LVADs vs. conservative therapy were performed before the availability of novel medications or used suboptimal medical therapy. This study aimed to report that long-term stabilization of patients entering a left ventricular assist device (LVAD) programme is possible with the use of aggressive conservative therapy. This is important because the excellent clinical stabilization provided by LVADs comes at the expense of significant complications.

METHODS AND RESULTS

This study was a single-centre prospective evaluation of consecutive patients with advanced heart failure (HF) fulfilling criteria for LVAD implantation based on clinical and echocardiographic characteristics, cardiopulmonary exercise test, and right heart catheterization results. Their initial therapy included inotropes, thiamine, beta-blockers, digoxin, spironolactone, hydralazine, and nitrates followed by the introduction of novel HF therapies. Coronary revascularization and cardiac resynchronization therapy were performed when indicated, and all patients were closely followed at our outpatient clinic. During the study period, 28 patients were considered suitable for LVAD implantation (mean age 63 ± 10.8 years, 92% men, 78% ischaemic, median HF duration 4 years). Clinical stabilization was achieved and maintained in 21 patients (median follow-up 20 months, range 9-38 months). Compared with baseline evaluation, cardiac index increased from 2.05 (1.73-2.28) to 2.88 (2.63-3.55) L/min/m² , left ventricular end-diastolic diameter decreased from 65.5 (62.4-66) to 58.3 (53.8-62.5) mm, and maximal oxygen consumption increased from 10.1 (9.2-11.3) to 16.1 (15.3-19) mL/kg/min. Three patients died and only four ultimately required LVAD implantation.

CONCLUSIONS

Notwithstanding the small size of our cohort, our results suggest that LVAD implantation could be safely deferred in the majority of LVAD candidates.

Effectiveness and cost-efficacy of diuretics home administration via peripherally inserted central venous catheter in patients with end-stage heart failure

BACKGROUND

End-stage heart failure (ESHF) is characterized by severe cardiac dysfunction with persistent disabling symptoms and recurrent acute decompensated heart failure (ADHF), despite guideline-directed medical therapy. The aim of this study was to evaluate the efficacy and safety of intravenous diuretics administration at home through a peripherally inserted central venous catheter (PICC) in ESHF patients.

METHODS AND RESULTS

Forty-one ESHF patients received PICC implantation for intravenous diuretic administration at home. The primary efficacy endpoint was the patient-level number of HF hospitalizations in the short (1-3 months), medium (six months), and long term (1 year), before and after PICC implantation. Pre- and post-PICC ADHF-free days were also evaluated as co-primary endpoint. Secondary endpoints comprised changes in clinical, laboratory and echocardiographic parameters, and device safety. A cost-effectiveness analysis was performed to estimate the economic impact of using PICC. For each time frame analyzed, a significant reduction in the number of hospitalizations due to ADHF was observed, resulting in a significant increase in ADHF-free days (71 ± 44 vs. 163 ± 136, p = 0.003). In matched patients' analysis, significant decrease in body weight (68 ± 16 kg vs. 63 ± 10 kg, p = 0.041) and mitral regurgitation grade 3/4 (55% vs. 18%, p < 0.001) were also observed. Freedom from PICC-related complications was observed in 61% of patients. A significant reduction in overall ADHF-hospitalizations cost was observed.

CONCLUSIONS

This proof-of-concept study demonstrates the effectiveness and safety of home administration of intravenous diuretic therapy via PICC in ESHF patients. This palliative cost-effective strategy can be taken in consideration for selected end-stage patients no longer responsive to conventional therapies.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Management of circulatory failure after Fontan surgery

With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.

Quality of life and long-term mortality in patients with advanced chronic heart failure treated with intermittent low-dose intravenous inotropes in an outpatient setting

AIMS

There are limited data on the effect of low-dose, intermittent inotropic therapy in an outpatient setting on the quality of life (QOL) in patients with advanced refractory heart failure (HF) symptoms. We aimed to analyse the effect of this treatment modality on QOL and subsequent survival.

METHODS AND RESULTS

The study population comprised 287 consecutive patients with advanced refractory HF symptoms who were treated with low-dose, intravenous intermittent inotropic therapy in the HF Day Care Service at Sheba Medical Centre between September 2000 and September 2012. All patients completed a baseline Minnesota Living with Heart Failure Questionnaire (MLWHFQ), and 137 (48%) completed a 1 year follow-up questionnaire. MLWHFQ scores' means ranged from 0 (better QOL) to 5 (worse QOL). Mean age was 68 ± 12, 86% were men, 77% had ischaemic cardiomyopathy, and the mean left ventricle ejection fraction (LVEF) was 26% ± 13. The mean baseline MLWHFQ score was 3.1 (±1), while the mean at 1 year of treatment was of 2.7 (±1.1), indicating an overall improvement in QOL associated with intermittent low-dose inotrope therapy (p < 0.01). Multivariate analysis showed that younger age, non-ischaemic cardiomyopathy, and worse renal function were independently associated with improvement in QOL at 1 year. Improvement in QOL was not associated with a significant survival benefit during subsequent follow-up.

CONCLUSIONS

In patients with advanced refractory HF symptoms, treatment with low-dose, intermittent intravenous inotropes in an outpatient setting is associated with significant improvement in QOL. However, improvement in QOL in this population does not appear to affect subsequent long-term survival.

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit

OBJECTIVE

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting.

METHOD

We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided.

RESULTS

Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control.

SIGNIFICANCE OF RESULTS

This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

Inotropes do not increase mortality in advanced heart failure

Inotrope use is one of the most controversial topics in the management of heart failure. While the heart failure community utilizes them and recognizes the state of inotrope dependency, retrospective analyses and registry data have overwhelmingly suggested high mortality, which is logically to be expected given the advanced disease states of those requiring their use. Currently, there is a relative paucity of randomized control trials due to the ethical dilemma of creating control groups by withholding inotropes from patients who require them. Nonetheless, results of such trials have been mixed. Many were also performed with agents no longer in use, on patients without an indication for inotropes, or at a time before automatic cardio-defibrillators were recommended for primary prevention. Thus, their results may not be generalizable to current clinical practice. In this review, we discuss current indications for inotrope use, specifically dobutamine and milrinone, depicting their mechanisms of action, delineating their patterns of use in clinical practice, defining the state of inotrope dependency, and ultimately examining the literature to ascertain whether evidence is sufficient to support the current view that these agents increase mortality in patients with heart failure. Our conclusion is that the evidence is insufficient to link inotropes and increased mortality in low output heart failure.

The adult with a fontan: a panacea without a cure? Review of long-term complications

The univentricular heart includes a spectrum of complex cardiac defects that are managed by staged palliative surgical procedures, ultimately resulting in a Fontan procedure. Since 1971, when it was first developed, the procedure has undergone several variations. These patients require lifelong management, including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function, together with multi-organ evaluation. As these patients enter middle age, there is increasing awareness of long-term complications and mortality. This review highlights the concept behind the staged surgical palliations, the unique single ventricle physiology and the long-term complications in this complex cohort of patients.

PDE3 inhibition in dilated cardiomyopathy

In dilated cardiomyopathy, a condition characterized by chamber enlargement and reduced myocardial contractility, decreases in β-adrenergic receptor density and increases in Gαi and β-adrenergic receptor kinase activities attenuate the stimulation of adenylyl cyclase in response to catecholamines. PDE3 inhibitors have been used to 'overcome' the reduction in cAMP generation by blocking cAMP hydrolysis. These drugs increase contractility in the short-term, but long-term administration leads to an increase in mortality that correlates with an increase in sudden cardiac death. Whether separate mechanisms account for these beneficial and harmful effects, and, if so, whether PDE3 can be targeted so as to increase contractility without increasing mortality are questions that remain unanswered.

Outpatient management of pediatric heart failure

The management of heart failure in children is becoming a specialized discipline within pediatric cardiology. Unlike the treatment of heart failure in adults, for which an extensive body of literature supports current treatment regimens, management of heart failure in children is largely guided by extrapolation from adult studies and expert opinion. This review focuses on the current state-of-the-art with respect to the outpatient management of heart failure in children.

Rotating inotrope therapy in a pediatric population with decompensated heart failure

OBJECTIVE

To describe the clinical course of a group of patients who received a rotating inotrope regimen, including levosimendan, for decompensated congestive heart failure.

DESIGN

Case series.

SETTING

Pediatric intensive care unit in a tertiary care children's hospital.

PATIENTS

Nine pediatric patients with severe, decompensated heart failure.

INTERVENTION

The study patients received a rotating inotrope regimen, including levosimendan, dobutamine, and, in some cases, milrinone.

MEASUREMENTS AND MAIN RESULTS

Six patients were weaned from positive-pressure ventilation. Eight patients were discharged from the intensive care unit, and seven survived to hospital discharge. Two patients were successfully bridged to orthotopic cardiac transplantation. The therapies were generally well tolerated.

CONCLUSIONS

Rotating inotropes were safe and seemed to be effective in this heterogeneous population of infants and children with decompensated heart failure. This therapeutic regimen warrants prospective comparative analysis.

Milrinone inhibits hypoxia or hydrogen dioxide-induced persistent sodium current in ventricular myocytes

Much evidence indicates that increased persistent sodium current (I(Na.P)) is associated with cellular calcium overload and I(Na.P) is considered to be a potential target for therapeutic intervention in ischaemia and heart failure. By inhibiting type III phosphodiesterase, milrinone increases intracellular cyclic adenosine monophosphate (cAMP), with a positive inotropic effect. However, the effect of milrinone on increased I(Na.P) under pathological conditions remains unknown. Accordingly, we investigated the effect of milrinone on increased I(Na.P) induced by hypoxia or hydrogen dioxide in guinea pig ventricular myocytes. While milrinone (0.01 mM or 0.1mM) or cAMP (0.1 mM) decreased I(Na.P) respectively in control condition, application of 1 microM H-89, a selective cAMP-dependant protein kinase inhibitor, prevented the effect of 0.1mM milrinone in control condition. Milrinone (0.1 mM) reduced the increased I(Na.P) induced by hypoxia. Furthermore, 0.01 mM or 0.1mM milrinone reduced the enhanced I(Na.P) induced by 0.3 mM hydrogen peroxide. In addition, 0.01 mM or 0.1 mM milrinone shortened action potential duration at 90% repolarization (APD(90)). Bath application of 0.3 mM hydrogen dioxide markedly prolonged APD(90), while 2 microM tetrodotoxin (TTX) reversed the prolonged APD(90). In the other two groups, 0.01 mM or 0.1 mM milrinone shortened the prolonged APD(90) induced by 0.3 mM hydrogen peroxide, ultimately 2 microM TTX causing a further decurtation of APD(90). These findings demonstrate that milrinone inhibited I(Na.P) under normal condition, hypoxia or hydrogen dioxide-induced I(Na.P), and the APD(90) prolonged by hydrogen dioxide-induced I(Na.P) in ventricular myocytes, which is associated with the mechanism of milrinone increasing intracellular cAMP.

Enzyme replacement therapy in the home setting for mucopolysaccharidosis VI: a survey of patient characteristics and physicians' early findings in the United States

Galsulfase, a Food and Drug Administration-approved enzyme replacement therapy for mucopolysaccharidosis VI, is administered once weekly in a hospital setting as a 4-hour intravenous infusion. To improve convenience and alleviate family responsibilities associated with clinic visits, some physicians are transitioning appropriate patients to home infusion therapy. An online survey was conducted with 3 physicians treating 4 patients with mucopolysaccharidosis VI to better understand the factors motivating the transition to home infusion therapy, identify characteristics of appropriate candidates, and evaluate the potential impact on the lives of patients and their families. Survey results showed that home infusion may offer patients and their families increased flexibility of schedule and enhanced family life.

Inotropic agents improve the peripheral microcirculation of patients with end-stage chronic heart failure

BACKGROUND

Skeletal muscle microcirculation impairment in patients with chronic heart failure (CHF) seems to correlate with disease severity. We evaluated the microcirculation by near-infrared spectroscopy (NIRS) occlusion technique before and after inotropic infusion.

METHODS

We evaluated 25 patients with stable CHF, 30 patients with end-stage CHF (ESCHF) receiving treatment with intermittent infusion of inotropic agents, and 12 healthy subjects. Thenar muscle tissue oxygen saturation (StO(2)%) was measured noninvasively by NIRS before, during, and after 3-minute occlusion of the brachial artery (occlusion technique) in all subjects and in patients with ESCHF before and after 6 hours of inotropic infusion (dobutamine and/or levosimendan) or placebo (N = 5).

RESULTS

Patients with ESCHF or CHF presented significantly lower StO(2)% than healthy subjects (74.5% +/- 7%, 78.6% +/- 6%, and 85% +/- 5%, respectively; P = .0001), lower oxygen consumption rate during occlusion (24.6% +/- 8%/min, 28.6% +/- 10%/min, and 38.1% +/- 11.1%/min, respectively; P = .001), and lower reperfusion rate (327% +/- 141%/min, 410% +/- 106%/min, and 480% +/- 133%/min, respectively; P = .002). After 6 hours of inotropic infusion, patients with ESCHF showed significantly increased StO(2)% (74.5% +/- 7% to 82% +/- 9%, P = .001), oxygen consumption rate (24.6% +/- 8%/min to 29.3% +/- 8%/min, P = .009), and reperfusion rate (327% +/- 141%/min to 467% +/- 151%/min, P = .001). No statistical difference was noted in the placebo group.

CONCLUSION

Peripheral muscle microcirculation as assessed by NIRS is impaired in patients with CHF. This impairment is partially reversed by infusion of inotropic agents in patients with ESCHF.

Assessment of quality of life in severe heart failure

Improvement of health-related quality of life (HRQL) is increasingly recognized as a priority in the management of heart failure (HF). In this review, we highlight the dramatic improvement in HRQL often observed in patients with severe HF and give particular emphasis to the nonpharmacologic therapy of cardiac resynchronization therapy, left ventricular assist devices, and cardiac rehabilitation. We juxtapose this to the less consistent improvement in HRQL seen with interventions aimed at treatment of acute HF syndromes. Conflicting data wherein HRQL improves in parallel to a detrimental or neutral effect on cardiovascular morbidity and mortality are also presented. We conclude with future directions and make the case for HF-specific instruments intended for the assessment of HRQL in hospitalized patients, longitudinal studies in which HRQL is followed over time, and continued attention to the preferences of those with severe and acute HF.

Medical management of the failing Fontan

The Fontan operation accomplishes complete separation of systemic venous blood from pulmonary venous circulation in patients with single ventricle anatomy. Operative survival since the first description of the Fontan operation is excellent in the current era through modifications in surgical techniques, identification of patient-specific risk factors, and advances in postoperative care. Improved early outcomes have also resulted in a decline in late mortality for patients who have undergone staged palliation with the Fontan operation. As the number of late survivors from the Fontan operation increases, caregivers will be evermore faced with the challenge of recognizing and managing the patient with failing Fontan physiology. Even after excellent early results, patients with single ventricle lesions remain at risk of progressive ventricular dysfunction, dysrhythmias, progressive hypoxemia, elevated pulmonary vascular resistance, and protein-losing enteropathy, which can result in morbidities including but not limited to, myocardial failure, thromboembolism, and stroke. Consequently, continued long-term survival of patients who undergo the Fontan operation is dependent upon preservation of single ventricle function, avoidance of late complications, and, in the patient with a failing Fontan, recognition and treatment of the underlying pathophysiologic process that has resulted in Fontan failure.

Outpatient continuous parenteral inotropic therapy as bridge to transplantation in children with advanced heart failure

BACKGROUND

Advanced heart failure in children is associated with high morbidity and mortality and is often refractory to standard medical therapy. The purpose of this study was to review our institutional experience with the use of outpatient parenteral inotropic therapy (PIT) for advanced chronic heart failure in children.

METHODS AND RESULTS

We reviewed the medical records of all patients treated with PIT as outpatients. Seven patients received outpatient PIT from 2/99 to 1/05 (mean age was 14.6 years +/- 3.7). Median duration of therapy was 10 weeks (range 4-84 weeks). The mean number of emergency department visits per patient was greater before starting PIT than after starting PIT (2.3 +/- 1.8 versus 1.1 +/- 2.2, P < .05). The mean number of hospital admissions from exacerbation of heart failure symptoms decreased after starting PIT (2.1 +/- 1.3 versus 0.6 +/- 0.8, P < .05). Mean EF% in patients with systolic dysfunction improved while on therapy (30 +/- 14% before versus 39 +/- 16% after, P < .05). There was 1 death and 5 complications in 2 patients. Six patients were successfully bridged to transplantation.

CONCLUSION

Outpatient continuous parenteral inotropic therapy may serve as a successful bridge to cardiac transplantation in selected pediatric outpatients.

Drug therapy recommendations from the 2005 ACC/AHA guidelines for treatment of chronic heart failure

OBJECTIVE

To review and discuss key aspects of the drug therapy recommendations in the American College of Cardiology (ACC)/American Heart Association (AHA) 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure (HF) in the Adult.

DATA SOURCES

Data were obtained from the ACC/AHA 2005 Guideline Update for Chronic HF. English-language clinical trials, observational studies, and pertinent review articles evaluating the pharmacotherapy of chronic HF were identified, based on MEDLINE searches through January 2006.

STUDY SELECTION

Articles presenting information that impacts the evidence base for recommendations regarding the use of various drug therapies in patients with chronic HF were evaluated.

DATA SYNTHESIS

The ACC/AHA 2005 Guideline Update for HF provides revised, evidence-based recommendations for the treatment of chronic HF. The new guidelines are based on a staging system that recognizes both the development and progression of HF. Recommendations are provided for 2 stages of patients (A and B) who do not yet have clinical HF but are clearly at risk and 2 stages (C and D) that include patients with symptomatic HF. The guidelines continue to emphasize the important role of neurohormonal blockade with angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-adrenergic blockers, and aldosterone antagonists. Based on recent trials, updated recommendations address the roles of combination therapy and the selective addition of hydralazine and isosorbide dinitrate. Along with specific drug recommendations, information on the practical use of various drugs is provided. Although the guidelines primarily focus on HF due to systolic dysfunction, general recommendations are also provided for patients with preserved systolic function.

CONCLUSIONS

The ACC/AHA 2005 Guideline Update provides evidence-based recommendations for healthcare professionals involved in the care of adults with chronic HF. Recent clinical trial findings have further clarified the evolving role of neurohormonal-blocking drugs in the prevention and treatment of HF.

Activity questionnaires; a useful tool in accessing heart failure patients

AIM

The aim of the study was to correlate the score derived from Specific Activity Questionnaire (SAQ), Left Ventricular Dysfunction 36 (LVD 36) and the Minnesota Living with Heart Failure Questionnaire (LIhFE) with peak oxygen consumption measured during maximal treadmill exercise spirometry in patients with heart failure.

METHODS

We prospectively studied 106 patients, average age 47+/-15.5 (mean+/-SD), with symptomatic heart failure. All were asked to answer the questions of the above mentioned questionnaires. Subsequently patients underwent treadmill exercise spirometry to measure peak oxygen consumption (VO2 peak ml/kg/min) using the Dargie protocol and to derive functional class according to the Weber classification system.

RESULTS

SAQ had a very high performance in classifying patients with a VO2 peak <20 ml/kg/min and those with a VO2 peak <14 ml/kg/min. The correlation between VO2 peak achieved and the METs corresponding to the score derived from SAQ according to the given answers was r=0.77 (p<0.01). The correlation between VO2 peak achieved and the score from LVD 36 was r=-0.74 (p<0.01). The correlation between VO2 peak achieved and the score from LIhFE was r=-0.71 (p<0.01).

CONCLUSION

The Specific Activity Questionnaire, the Left Ventricular Dysfunction and the Minnesota Living with Heart Failure Questionnaire were used to predict aerobic capacity and all correlated significantly with peak VO2 achieved from exercise spirometry. The above questionnaires represent a useful method to access heart failure patients and are valuable for those unable to undergo a treadmill test.

Idiopathic dilated cardiomyopathy in children: a single medical center's experience

BACKGROUND

The prognosis of patients with idiopathic dilated cardiomyopathy (DCM) is poor. Most patients die while waiting for cardiac transplantation because of the small number of donors in Taiwan. The purpose of this study was to review our experience with pediatric patients diagnosed with idiopathic DCM and attempt to discover prognostic factors.

METHODS

Eighteen patients with idiopathic DCM presenting between 1990 and 2004 were identified. They were classified into 2 groups according to outcome: group 1 comprised 13 patients who died; group 2 comprised 5 who survived. Clinical findings and laboratory investigations were compared between the 2 groups.

RESULTS

The age at initial diagnosis for the 18 patients (11 males, 7 females) ranged from fetus to 13 years (median, 3 months). The follow-up period ranged from 12 days to 44 months (median, 7 months) in group 1, and from 1 to 48 months (median, 39 months) in group 2. Of the 18 patients, 13 (72%) died: 11 died from severe heart failure while waiting for cardiac transplantation. The cumulative survival rate was 50% at 1 year and 28% at 4 years. The presence of arrhythmia and low left ventricular ejection fraction were predictive of a poor outcome.

CONCLUSION

The diagnosis of idiopathic DCM in children is associated with a generally poor prognosis. The lack of available donors results in significant mortality for pediatric patients awaiting transplantation. Advocating organ donation to increase the size of the organ donor pool is needed to significantly reduce the mortality rate in such patients.

Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study

BACKGROUND

The prognostic value of serum sodium in patients hospitalized for worsening heart failure has not been well defined.

METHODS AND RESULTS

The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study randomized 949 patients with systolic dysfunction hospitalized for worsening heart failure to receive 48 to 72 hours of intravenous milrinone or placebo in addition to standard therapy. In a retrospective analysis, we investigated the relationship between admission serum sodium and the primary end point of days hospitalized for cardiovascular causes within 60 days of randomization, as well as the secondary end points of in-hospital mortality, 60-day mortality, and 60-day mortality/rehospitalization. The number of days hospitalized for cardiovascular causes was higher in the lowest sodium quartile: 8.0 (4.5, 18.5) versus 6 (4, 13) versus 6 (4, 11.5) versus 6 (4, 12) days (P<0.015 for comparison with the lowest quartile). Lower serum sodium was associated with higher in-hospital and 60-day mortality: 5.9% versus 1% versus 2.3% versus 2.3% (P<0.015) and 15.9% versus 6.4% versus 7.8% versus 7% (P=0.002), respectively. There was a trend toward higher mortality/rehospitalization for patients who were in the lowest sodium quartile. Multivariable-adjusted Cox proportional hazards analysis showed that serum sodium on admission, when modeled linearly, predicted increased 60-day mortality: sodium (per 3-mEq/L decrease) had a hazard ratio of 1.18 with a 95% CI of 1.03 to 1.36 (P=0.018).

CONCLUSIONS

In patients hospitalized for worsening heart failure, admission serum sodium is an independent predictor of increased number of days hospitalized for cardiovascular causes and increased mortality within 60 days of discharge.

Heart Failure in the Elderly

Incidence and prevalence of heart failure are particularly common with advancing age, with notoriously grim prognoses. The absolute number of heart failure patients will undoubtedly surge as the population of older adults continues to escalate. This review emphasizes the importance of factors inherent in aging itself and the resulting predisposition to disease. Physiologic changes associated with cardiovascular aging fundamentally increase susceptibility to heart failure and to complexity of heart failure management. Likewise, typical age-associated diet and lifestyle changes compound risks of heart failure through mechanisms connected to the substrate of disease. In this review, the authors first summarize the demographics of heart failure and the intrinsic aspects of aging and lifestyle that predispose to heart failure. They then expand on related intricacies of diagnosis and therapy. Orientation to heart failure, particularly as a disease of aging, can help critically refine management of acute and chronic disease, as well as foster preventive strategies to reduce incidence of this common malady.

Outpatient cardiovascular management utilizing impedance cardiography

Over the past decade, noninvasive hemodynamic and thoracic fluid status monitoring via impedance cardiography has provided clinicians practicing in the outpatient setting with a valuable tool for managing a myriad of cardiovascular disorders. This article reviews impedance cardiography technology and the use of impedance cardiography in the home and outpatient clinic settings for the assessment and management of heart failure, resistant hypertension, and dual-chamber pacemaker optimization.

Morbidity and mortality of UNOS status 1B cardiac transplant candidates at home

BACKGROUND

On January 20, 1999, UNOS listing regulations changed, allowing stable patients on inotropic support (Status IB) to be discharged home until cardiac transplant. The outcome, morbidity and cost savings of this new strategy has not been evaluated.

METHODS

From 1/20/99 through 1/1/01, 155 patients were classified as UNOS Status 1B at our institution; 64 patients were never discharged and 91 were discharged home. Criteria for discharge were hemodynamic stability on low-dose, single-agent parenteral inotropic infusion, defined as dobutamine at a dose <7.5 microg/kg/min or milrinone <0.5 microg/kg/min. Data on re-admissions were collected prospectively. The frequency of complex ventricular arrhythmias was evaluated in a sub-group discharged with external or internal cardiodefibrillators (n = 38).

RESULTS

Total Status I time to transplant for the 91 discharged patients was 139 +/- 91 days, with 87 +/- 67 days spent at home. Inpatient time to transplant was still high, with a mean of 51 +/- 45 days. The in-hospital time was comparable to that of the 64 patients who were never discharged (51 +/- 41 days). Fifty-nine percent of discharged patients were re-admitted, with 37% of patients requiring more than 1 admission. Sixty-six percent of admissions were for worsening heart failure (CHF), and 34% for infection or occlusion of the indwelling intravenous line. No significant arrhythmic events were recorded in the 38 patients who had internal or external cardiodefibrillators. Two patients died suddenly at home. One patient had declined to wear the external cardiodefibrillator. The other patient was not wearing the defibrillator at the time of the event, and in 634 hours of previous monitoring he had had no events.

CONCLUSIONS

In UNOS Status 1B patients awaiting cardiac transplant on home inotropic therapy, mortality remains low but the re-admission rate was high. There appeared to be a low incidence of complex ventricular arrhythmias.

Diagnosis and management of pediatric myocarditis

Myocarditis is an insidious inflammatory disorder of the myocardium. As a clinical entity, it has been recognized for two centuries, but it defies traditional diagnostic tests. A greater understanding of the immune response underlying the pathobiology of the disorder can lead to a more rational therapeutic approach. The presentation, course and therapeutic options appear to be different in the pediatric compared with the adult population. An understanding of the difference between fulminant and acute progressive myocarditis has led to successful treatment strategies. A variety of new therapies are available, including antiviral agents, immunosuppression, and modulation of the biological response to inflammation. The specific question for patients with myocarditis is whether regimens designed to reduce or eliminate inflammation can provide clinical benefits compared with conventional heart failure therapy. This review highlights pathological mechanisms, modalities of diagnosis, and novel therapies which may improve outcomes.

Relationship between the Minnesota Living With Heart Failure Questionnaire and key ventilatory expired gas measures during exercise testing in patients with heart failure

PURPOSE

This study assessed the relationship between the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) and key ventilatory expired gas measures during a symptom-limited exercise test in the heart failure (HF) population. Specifically, is there evidence to indicate that perceived quality of life (QOL) influences exercise performance independent of physiologic function in the HF population?

METHODS

Thirty-one subjects (21 male/10 female), diagnosed with compensated HF, underwent exercise testing and completed the MLWHFQ. Mean age and left ventricular ejection fraction were 52.8 years and 27.2%, respectively. Partial correlation, controlling for age and sex, assessed the relationship between MLWHFQ (overall and subscores) and key ventilatory expired gas measures. Intraclass correlation coefficient (ICC) analysis was used to determine reliability of the MLWHFQ.

RESULTS

MLWHQ overall score (mean = 38.9, median = 36.0), physical subscore (mean = 14.8, median = 16.0), and psychosocial/symptomatology subscore (mean = 24.1, median = 19.0), were significantly correlated (P < or =.05) with peak oxygen consumption (VO2). The relationship between MLWHFQ and the minute ventilation-carbon dioxide production (VE/VCO2) slope was, however, not significant. ICC analysis revealed high reliability (0.95) for the MLWHFQ.

CONCLUSIONS

The MLWHFQ demonstrates a significant relationship with peak VO2, a measure whose validity is dependent upon subject effort. VE/VCO2 slope, which is independent of subject effort and therefore potentially a better predictor of true physiologic function, does not appear to have a relationship with perceived QOL. These findings have implications for how the MLWHFQ is assessed, related to an exercise test, and used during clinical practice.

Positive inotropic drug infusions for patients with heart failure: current controversies and best practice

Patients who experience severe symptoms of heart failure and repeated hospitalizations for exacerbations may benefit from positive inotropic drug infusion therapy such as dobutamine or milrinone. This article provides an overview of inotropic drug delivery in the home including current controversies and best practices to ensure safe home care policies and practice.

Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables

OBJECTIVE

To assess health related quality of life of patients with congestive heart failure; to compare their quality of life with the previously characterised general population and in those with other chronic diseases; and to correlate the different aspects of quality of life with relevant somatic variables.

SETTING

University hospital.

PATIENTS AND DESIGN

A German version of the generic quality of life measure (SF-36) containing eight dimensions was administered to 205 patients with congestive heart failure and systolic dysfunction. Cardiopulmonary evaluation included assessment of New York Heart Association (NYHA) functional class, left ventricular ejection fraction, peak oxygen uptake, and the distance covered during a standardised six minute walk test.

RESULTS

Quality of life significantly decreased with NYHA functional class (linear trend: p < 0.0001). In NYHA class III, the scores of five of the eight quality of life domains were reduced to around one third of those in the general population. The pattern of reduction was different in patients with chronic hepatitis C and major depression, and similar in patients on chronic haemodialysis. Multiple regression analysis showed that only the NYHA functional class was consistently and closely associated with all quality of life scales. The six minute walk test and peak oxygen uptake added to the explanation of the variance in only one of the eight quality of life domains (physical functioning). Left ventricular ejection fraction, duration of disease, and age showed no clear association with quality of life.

CONCLUSIONS

In congestive heart failure, quality of life decreases as NYHA functional class worsens. Though NYHA functional class was the most dominant predictor among the somatic variables studied, the major determinants of reduced quality of life remain unknown.

The dilemma of late-stage heart failure. Rationale for chronic parenteral inotropic support

The available evidence suggests that while chronic inotropic support likely exerts a long-term deleterious effect on survival, their use is accompanied by short-term enhancements in symptomatology and decreases in medical resource use, thereby curtailing the overall medical costs. The decision to use chronic parenteral inotropic support should not be made lightly and must be considered only after all evidence based therapeutic options has been investigated thoroughly and tried (Fig. 1). This should include not only hemodynamic monitoring-based drug therapy but [figure: see text] also appropriate consideration for options such as heart transplantation or patient enrollment into large-scale drug trials that seek to answer pertinent issues relating to various aspects of advanced heart failure therapeutics. The use of parenteral inotropic support as a chronic bridge to transplantation is accepted widely but remains controversial in other scenarios. For instance, when refractory congestion or hypoperfusion is exhibited in the absence of any definitive medical or mechanical option, it may be wise to contemplate inotropic support after appropriate informed consent has been obtained from the patient. Lastly, it is of great importance to continually seek ways to transit the patient from this approach to a definitive therapeutic end point, such as with transition to oral beta-blockade, which may be better tolerated in the patient with advanced heart failure using an inotropic umbrella.

Inotropic therapy for heart failure: an evidence-based approach

BACKGROUND

Agents that increase cardiac contractility (positive inotropes) have beneficial hemodynamic effects in patients with acute and chronic heart failure but have frequently led to increased mortality when given on a long-term basis. Despite this fact, inotropes remain commonly used in the management of heart failure.

METHODS

We reviewed the available data on short- and long-term inotrope use in heart failure, emphasizing high-quality evidence on the basis of randomized trials that were powered to address clinical end points.

RESULTS

Available data suggest that long-term inotropic therapy has a negative impact on survival in patients with heart failure, regardless of the agent used. The data that inotropic therapy improves quality of life are mixed. High-quality randomized evidence is lacking for the use of inotropes for other heart failure indications, such as for acute decompensations or as a "bridge to transplant."

CONCLUSIONS

On the basis of the available evidence, the routine use of inotropes as heart failure therapy is not indicated in either the acute or chronic setting. Potentially appropriate uses of inotropes include as temporary treatment of diuretic-refractory acute heart failure decompensations or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Inotropes also may be appropriate as a palliative measure in patients with truly end-stage heart failure. A model of heart failure pathophysiologic features that combines an understanding of both hemodynamic and neurohormonal factors will be required to best develop and evaluate novel treatments for advanced heart failure.

Rational use of inotropic therapy in heart failure

Despite their theoretic appeal, agents that increase cardiac contractility (positive inotropes) have consistently been shown to increase mortality when given chronically to patients with heart failure. The routine use of inotropes as heart failure therapy in either the acute or the chronic setting is not supported by the available data. Some appropriate uses of inotropes are as temporary treatment of diuretic-refractory acute heart failure decompensations, or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Although controversial, the use of inotropes as a palliative measure in the small subset of patients with truly end-stage heart failure may be appropriate. An understanding of the appropriate goals of therapy is important for both patients and physicians if rational decisions about the use of inotropes are to be made.

Successful weaning from milrinone of a patient with severe congestive heart failure using carvedilol

Congestive heart failure is a major and growing health care concern worldwide, and mortality in patients with severe heart failure is high. Few options are available to patients with New York Heart Association class IV heart failure refractory to oral medical therapy. Over the last 15-20 years milrinone, a phosphodiesterase-III inhibitor, has been used occasionally to treat patients with acute heart failure and as a bridge to heart transplantation and, more recently, has been used intermittently or continuously on an outpatient basis. We report a patient with severe, chronic congestive heart failure, whom we treated successfully with continuous milrinone infusions as an outpatient. We were able to wean him of the milrinone after successful up-titration of carvedilol. Nine months after discontinuation of milrinone the patient remains stable in New York Heart Association class I on high dose carvedilol. Research is required to validate the possibility that patients with severe heart failure may be successfully weaned from milrinone using carvedilol and achieve significant improvement of their functional status and quality of life. This may prove to be an effective strategy for the treatment of selected patients with severe, chronic congestive heart failure. (c)2001 by CHF, Inc.

Intermittent positive inotrope infusion in the management of end-stage, low-output heart failure

The US Food and Drug Administration (FDA) has approved the use of the parenteral positive inotropes (dobutamine and milrinone) for short-term treatment of patients with acute, decompensated heart failure (HF). Despite the limited approved indication, parenteral, positive inotropes have been used clinically for long-term therapy to support the circulation as a bridge to transplant among patients waiting for an organ donor. The increasing number of patients with HF who are ineligible for transplant and the inadequate supply of donor organs have generated interest in the use of intermittent, parenteral positive inotropes for palliative therapy in patients with end-stage HF. Efforts by some clinicians to provide optimal symptomatic relief while controlling health care costs have produced a number of HF clinics that provide intermittent, parenteral inotropic therapy as a component of HF therapy. This article reviews the evidence for and against intermittent infusion of these agents in the ongoing care of people with end-stage HF who are not candidates for transplant. The available evidence indicates that intermittent positive inotropic infusion is associated with fewer HF symptoms, increased functional status, reduced health care costs, but also with increased mortality.

Milrinone for long-term pharmacologic support of the status 1 heart transplant candidates

BACKGROUND

We determined the efficacy of long-term therapy with milrinone alone or in combination with inotropic agents in status 1 heart transplant candidates as a pharmacological support until heart transplantation.

METHODS

Hemodynamic and biochemical variables were recorded in 29 status 1 men with symptoms of severe congestive heart failure, who received continuous intravenous milrinone alone (group 1, n = 21) or in combination with inotropic agents (group 2, n = 8) while awaiting heart transplantation.

RESULTS

Symptomatic relief was noted in all patients of both groups without any preoperative deaths. One patient (4.8%) of group 1 died on the second day and 1 patient of group 2 died 16.4 months after transplantation. Although pulmonary capillary wedge pressure (group 1, p = 0.021; group 2, p = 0.0002), mean pulmonary artery pressure (group 1, p = 0.051; group 2, p = 0.004), and pulmonary vascular resistance (group 1, p = 0.0026; group 2, p = 0.056) were reduced by 1 hour after the onset of treatment and maintained unchanged until transplantation, the changes in mean pulmonary artery pressure in group 1 and pulmonary vascular resistance in group 2 were statistically insignificant except in the posttransplantation period.

CONCLUSIONS

Long-term therapy with milrinone in combination with inotropic agents is safe and effective when only milrinone infusion is inadequate for pharmacologic support in status 1 candidates.

Intravenous therapy for advanced heart failure

Because of the standard use of oral neurohumoral antagonists, the role of intravenous agents for advanced heart failure patients has changed profoundly. Their current use as medical therapy is restricted to two indications: first, as short-term infusion (hours to days) in advanced heart failure patients who decompensate into a symptomatic New York Heart Association class IV condition and who are admitted for rapid hemodynamic support with intravenous vasodilators or inotropes; in these patients after hemodynamic and clinical stabilization, optimization of conventional heart failure therapy has to be reconsidered; second, as long-term application in heart transplantation candidates who are in a similar desperate condition although already receiving maximal oral heart failure therapy.

Optimising management of patients with advanced heart failure: the importance of preventing progression

Heart failure is a highly complex, progressive and deadly disease. When incorrectly treated, it results in irreversible structural damage to the myocardium and resists any conventional treatment. This stage has been arbitrarily termed refractory heart failure. However, with timely and sufficiently applied neurohumoral antagonists, progression can be prevented, or at least delayed. In contrast, as soon as heart failure has become moderate or severe due to advanced left ventricular dysfunction, polypharmacy is the rule. Physicians should make every effort to maintain or reconsider optimal neurohumoral antagonist therapy in such patients, even if symptomatic improvement from these agents may be slow. Proper use of diuretics is essential not only for symptom relief but also to achieve full benefit from angiotensin converting enzyme inhibitors and beta-blockers. Digitalis may be particularly indicated in severe heart failure, irrespective of rhythm. Adjunctive regimens can be helpful in specific patients, but evidence of their salutary effects to prolong life is lacking. In the decompensated state, tailoring intravenous therapy to haemodynamic goals followed by (re-)institution of optimal oral therapy is an option. Only if these strategies fail is heart transplantation justified. While waiting for a donor, patients have been bridged with various intravenous agents, most often inotropes, but symptom relief is associated with risk of increased mortality due to these drugs. New hope emerges from drugs interfering with endothelin and the cytokines, and from research into increasing contractility with calcium sensitising agents. Even though these developments follow established routes, they may enable a more effective approach to prevent worsening heart failure in every single patient.

Tolerability of extended duration intravenous milrinone in patients hospitalized for advanced heart failure and the usefulness of uptitration of oral angiotensin-converting enzyme inhibitors

Milrinone is a phosphodiesterase inhibitor that has been shown to improve hemodynamic parameters in patients with class III to IV heart failure when administered intravenously for < or =48 hours. This study examines the tolerability of long-term intravenous milrinone therapy and assesses its utility in allowing upward titration of oral vasodilator agents. A retrospective review of hospital records identified 63 patients who underwent hemodynamic monitoring and received intravenous milrinone for >24 hours in a critical care setting. Hemodynamics and medications were recorded before and after 24 hours of milrinone therapy. Additional medications, as well as any adverse events, were recorded throughout milrinone therapy. The mean dose of milrinone was 0.43 +/- 0.10 microg/kg/min, with a mean duration of 12 +/- 15 days (range 1 to 70). Therapy was continued for >48 hours in 89% of patients. After 24 hours of milrinone therapy, patients exhibited significant improvements in pulmonary artery pressures, pulmonary capillary wedge pressures, and cardiac index. When compared with baseline, significantly more patients received angiotensin-converting enzyme (ACE) inhibitors after 24 hours of milrinone and at the end of milrinone therapy (67% vs 86%, p <0.01). Likewise, significantly more patients also received oral hydralazine and/or nitrates at the end of milrinone therapy (38% vs 65%, p <0.01) when compared with baseline. The mean doses of most oral medications at the 3 time periods were similar. The ACE inhibitor dose was significantly higher at the end of milrinone therapy when compared with baseline, and hydralazine dose was significantly higher at the end of therapy when compared with 24 hours. Few adverse effects were noted, with only 10% of patients experiencing symptomatic ventricular tachycardia and 2 patients with significant hypotension requiring discontinuation of the drug. The adverse events were similar in the group of patients who received milrinone for > or =7 days compared with the entire cohort. Milrinone was well tolerated over the long term in a controlled inpatient setting, and allowed uptitration of oral vasodilator therapy.

Managing inotrope therapy noninvasively

Intermittent and continuous outpatient and home inotrope infusions have contributed to a decreased mortality rate and improved quality of life in the patient with end-stage congestive heat failure. Before the advent of noninvasive hemodynamic monitoring, available with thoracic electrical bioimpedance, initial dosage and titration were determined solely with invasively acquired data requiring hospital admission or with patients' subjective data. Thoracic electrical bioimpedance monitoring of patients receiving inotrope therapy provides objective documentation of drug efficacy, developing tolerance, and optimal dosage.