Inotrope use and outcomes among patients hospitalized for heart failure: impact of systolic blood pressure, cardiac index, and etiology

Background: Inotropes are widely used in hospitalized systolic heart failure (HF) patients, especially those with low systolic blood pressure (SBP) or cardiac index. In addition, inotropes are considered to be harmful in nonischemic HF.

Methods and results: We examined the association of in-hospital inotrope use with (1) major events (death, ventricular assist device, or heart transplant) and (2) study days alive and out of hospital during the first 6 months in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness, which excluded patients with immediate need for inotropic therapy. Predefined subgroups of interest were baseline SBP <100 versus ≥ 100 mm Hg, cardiac index <1.8 vs ≥ 1.8 L min(-1) m(-2), and ischemic versus nonischemic HF etiology. Inotropes were frequently used in both the <100 mm Hg (88/165 [53.3%]) and the ≥ 100 mm Hg (106/262 [40.5%]) SBP subgroups and were associated with higher risk for major events in both subgroups (adjusted hazard ratio [HR] 2.85, 95% confidence interval [CI] 1.59-5.12 [P < .001]; and HR 1.86, 95% CI 1.02-3.37 [P = .042]; respectively). Risk with inotropes was more pronounced among those with cardiac index ≥ 1.8 L min(-1) m(-2) (n = 114; HR 4.65, 95% CI 1.98-10.9; P < .001) vs <1.8 L min(-1) m(-2) (n = 82; HR 1.48, 95% CI 0.61-3.58; P = .39). Event rates were higher with inotropes in both ischemic (n = 215; HR 2.64, 95% CI 1.49-4.68; P = .001) and nonischemic (n = 216; HR 2.19, 95% CI 1.18-4.07; P = .012) patients. Across all subgroups, patients who received inotropes spent fewer study days alive and out of hospital.

Conclusions: In the absence of cardiogenic shock or end-organ hypoperfusion, inotrope use during hospitalization for HF was associated with unfavorable 6-month outcomes, regardless of admission SBP, cardiac index, or HF etiology.