Elsevier

American Heart Journal

Volume 153, Issue 1, January 2007, Pages 98-104
American Heart Journal

Clinical Investigation
Congestive Heart Failure
Use and impact of inotropes and vasodilator therapy in hospitalized patients with severe heart failure

https://doi.org/10.1016/j.ahj.2006.09.005Get rights and content

Background

Treatment of decompensated heart failure often includes the use of intravenous vasoactive medications, but the effect on outcome has not been clearly defined.

Methods

Data from 433 patients enrolled in the ESCAPE trial were analyzed to determine 6-month risks of all-cause mortality and all-cause mortality plus rehospitalization associated with the use of vasodilators, inotropes, and their combination. Patients had a mean left ventricular ejection fraction of 19%, 6-minute walk distance of 414 ft, and systolic blood pressure of 106 mm Hg. The main outcome measure was multivariable risk-adjusted 6-month hazard ratios (HRs).

Results

Overall 6-month mortality was 19%. Risk-adjusted HRs were not statistically significant for vasodilators (1.39, 95% CI 0.64-3.00), but were significant for inotropes (2.14, 95% CI 1.10-4.15) and the combination (4.81, 95% CI 2.34-9.90). Risk-adjusted 6-month mortality plus rehospitalization HRs were not significant for vasodilators (1.20, 95% CI 0.81-1.78, P = .37), but were significant for inotropes (1.96, 95% CI 1.37-2.82, P < .001) and their combination (2.90, 95% CI 1.88-4.48, P = .001). The decision to use vasodilators or inotropes was determined by hemodynamic parameters and renal function, but the main factor was treatment site.

Conclusions

In ESCAPE, the choice of medications was mainly determined by the treatment site. Use of inotropic agents was associated with adverse outcomes, whereas the use of vasodilators was not. Inotropes in combination with vasodilators identified a group with the highest mortality. Prospective studies are needed to establish the appropriate use of vasoactive medications in this population.

Section snippets

Methods

The design of the ESCAPE trial has been previously described.8 Briefly, ESCAPE was a multicenter randomized evaluation of 433 patients hospitalized with severe decompensated HF at 26 academic medical centers in the United States and Canada. Additional inclusion criteria were age >18 years; documented history of HF for ≥3 months; treatment with angiotensin-converting enzyme (ACE) inhibitors and diuretics for ≥3 months; documented left ventricular ejection fraction (LVEF) of <30% in the 12 months

Results

A total of 433 patients were enrolled in the ESCAPE trial. Of these, 215 were randomly assigned to the PAC group and 218 to the clinical assessment group. The mean time from hospital admission to randomization was 1.3 days. Table I summarizes the demographic and clinical characteristics of these patients. Patients had a mean age of 56 years, 74% were male, 60% were white, and 50% had an ischemic etiology for their HF. All patients had significant systolic dysfunction with a mean LVEF of 19.3%.

Discussion

This analysis provided information on the relative use of vasoactive medications and the factors determining their selection by clinicians for the treatment of patients with severe decompensated HF. Renal function and right atrial pressure were significant predictors for use of inotropes, whereas renal function and PCWP predicted the use of vasodilators. These data suggest that impairments of renal function and more severe hemodynamic abnormalities seem to influence the use of vasoactive

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This study was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.

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