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Palliative Inotropes in Advanced Heart Failure: Comparing Outcomes Between Milrinone and Dobutamine

Published:September 16, 2022DOI:https://doi.org/10.1016/j.cardfail.2022.08.007

      Highlights

      • Long-term therapy with palliative inotropes is often the only option for patients with advanced heart failure who are not candidates for cardiac transplant or a left ventricular assist device. Comparison of outcome data between dobutamine and milrinone in these patients is limited.
      • Our study finds improved survival with chronic intravenous milrinone therapy as compared with dobutamine in these patients (1-year mortality 58% vs 84%, P < .001). Improved survival from milrinone is attributed to better optimization of guideline-directed medical therapy, primarily beta-blocker therapy, which is usually not prescribed concomitantly with dobutamine.
      • There are important prognostic implications of the choice of inotropic agent as long-term therapy for these patients. Even for palliative purposes, milrinone should be the preferred agent owing to better patient survival when combined with optimal guideline-directed medical therapy.

      Abstract

      Background

      We sought to describe and compare outcomes among advanced patients with heart failure (not candidates for orthotopic heart transplant/left ventricular assist device) on long-term milrinone or dobutamine, which are not well-studied in the contemporary era.

      Methods and Results

      We included adults with refractory stage D heart failure who were not candidates for orthotopic heart transplant or left ventricular assist device and discharged on palliative dobutamine or milrinone. The primary outcome was 1-year survival. A 6-month predictor of survival analysis was conducted. A total of 248 patients (133 on milrinone, 115 on dobutamine) were included. There were no differences in baseline comorbidities between milrinone and dobutamine cohorts, except for the prevalence of chronic kidney disease, which was higher in the dobutamine group. On discharge, the proportion of patients on beta-blockers and mineralocorticoid antagonists was higher in milrinone group. Overall, the 1-year mortality rate was 70%. The dobutamine cohort had a significantly higher 1-year mortality rate (84% vs 58%, P <0.001). The type of inotrope did not predict survival at 6 months when adjusted for discharge medications and comorbidities. Beta-blockers and angiotensin-converting enzyme/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor continued at discharge predicted survival at 6 months.

      Conclusions

      The 1-year mortality from palliative inotropes remains high. Compared with dobutamine, use of milrinone was associated with improved survival owing to better optimization of guideline-directed medical therapy, primarily beta-blocker therapy.

      Graphical abstract

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