Inotropes Increase Mortality in Advanced Heart Failure

Sirtaz Adatya, MD Assistant Professor of Medicine

Inotropes Increase Mortality

Sirtaz Adatya, MD Assistant Professor of Medicine

Objectives

1) Inotropes in HF are over Utilized

2) Evidence is sufficient to link inotropes to increased mortality

3) Mechanical Circulatory Support is superior to inotropic therapy

Symptoms No Orthopnea/PND

PCWP ≤16 No exertional Dyspnea

RA<8 No Edema

SBP≥80 JVP<8

Goals of Therapy

Outcomes -Maximizing end organ

perfusion -Quality of Life

-Prevent Readmissions -Decreasing Mortality

Congestion at Rest

No

No

Yes

Yes

Warm and Dry PCW normal CI normal (compensated)

Cold and Dry PCW low/normal CI decreased

Cold and Wet PCW Elevated CI decreased

Warm and Wet PCW elevated CI Normal

Selection for Treatment

Normal SVR-Inotropic Therapy

HI SVR-Vasodilators

Low Perfusion Rest

Stevenson LW. Eur J heart Failure 1999;1:251-257

HF Therapy 1974

Oxygen

Diuretics

Vasodilators

Inotropes

In Hospital Inotrope Therapy

Real World Data: 65,000 patient cases and 263 hospitals, almost 2 X increase in 6 months mortality

Rose et al. NEJM 2001

Chronic Inotrope Therapy

REMATCH Trial INTREPID Trial

Rogers et al. J Am Coll Cardiol 2007

RRR: 48%, ARR 29% 1 yr mortality

Pulsatile LV device

Novacor Device

Circ Heart Failure 2009

Intermittent Inotrope Therapy

Inotrope + Medical Therapy

Milrinone + B-Blocker ≠ No real DATA Prominent Nuclear Physicist “based on the laws of the Universe adding two opposing forces should result in neutrality”

Inotrope Therapy + B-Blockade

-Retrospective Post-Hoc -multivariate adjustment -No clear definition of ICM

Inotrope Therapy!

Francis, Bartos, Adatya J AM Coll Cardio 2014;63:2069-78

Options…..

Who needs Coronaries?….Eat a Big Mac! We have LVADs.

YIPEE!

“I’d Like a second Opinion”

Inotropes Stagnant…MCS Advancing!

ISHLT

European

Guidelines

ACC

“Be OSLER!”

“Master Clinician” VS. Wild…Wild…West!

Thank you Sirtaz Adatya, MD

Inotropes Increase Mortality

“Inotropes obsolete”

“Era Mechanical Circulatory Support”