Elsevier

American Heart Journal

Volume 135, Issue 1, January 1998, Pages 121-129
American Heart Journal

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

https://doi.org/10.1016/S0002-8703(98)70352-7Get rights and content

Abstract

Background End-stage congestive heart failure (CHF) is associated with a high mortality rate and is often refractory to standard medical treatment. Although parenteral inotropes have been beneficial in hospitalized patients, their use in outpatients has been limited by toxicity and tachyphylaxis. Methods and Results To determine whether patients with end-stage CHF could safely tolerate intermittent outpatient inotropic therapy and demonstrate both symptomatic and functional improvement with these agents, we studied the effects of low-dose, intermittent home infusions of the inotrope/vasodilator milrinone in 10 patients with end-stage CHF. After showing hemodynamic improvement with milrinone while hospitalized, central lines were placed and patients were given the drug at home with small portable infusion pumps, starting at 3 days a week for 6 hours at a time over a 3-month period. Patients tolerated the drug well, with no deaths and a fourfold decrease in hospitalizations during the study. Arrhythmias were minimal and angina decreased in two patients. Mean total, physical, and emotional scores on the Minnesota Living with Heart Failure Questionnaire reflected a general trend of symptomatic improvement throughout the infusion period. The mean number of reported hours of improvement after infusion progressively increased throughout the study, producing a mean of 25 hours of postinfusion improvement during the final week (p < 0.01). Repeat hemodynamic study at the end of the 3-month period showed trends toward improvement in cardiac function. ConclusionThis is the first study to demonstrate safety, efficacy, hemodynamic, and functional improvement in patients receiving low-dose, intermittent outpatient milrinone therapy. We believe this improvement partly relates to a “training” effect on the heart or peripheral muscles and circulation. These promising results suggest that given appropriately, inotropes have an important therapeutic role in the outpatient treatment of end-stage CHF. (Am Heart J 1998;135:121-9.)

Section snippets

Patients

Patients with late-stage CHF who continued to have symptoms at rest despite maximal outpatient medical therapy were screened. Each prospective subject signed an informed consent for 3 days of inpatient milrinone infusion under close monitoring in the intensive care unit. Patients who demonstrated hemodynamic and symptomatic improvement without adverse side effects were offered participation in the study. All patients considered for the study had symptoms at rest or with minimal exertion.

Ten

Hospital infusions

Three patients initially screened showed either no sustained effects of milrinone (one patient) or adverse effects, including tachycardia (one patient) and arrhythmia (one patient).

The data from the initial hospitalizations for milrinone infusion are summarized in Table I. The mean cardiac output increased from 4.1 ± 0.4 L/min at baseline to a maximum of 5.5 ± 0.3 L/min (p < 0.001). Mean PAWP decreased from 23.8 ± 2.6 mm Hg to 15.2 ± 1.7 mm Hg (p = 0.002), and mixed venous oxygen saturation

Discussion

Because inotropes have been useful therapeutic agents for CHF exacerbations for more than a decade, attempts have been made to institute their use on an outpatient basis. The majority of these trials have used the synthetic β-1 agonist dobutamine. Although studies have shown improvement in cardiac index, New York Heart Association functional class and systemic vascular resistance,17, 18, 19 the initial excitement over the potential use of these drugs in an outpatients basis has considerably

Acknowledgements

We thank Steven Carter for technological support and Dr. Ralph Shabetai for his continued encouragement and support.

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    From the Division of Cardiology, Veterans Affairs Medical Center, and University of California, San Diego.

    ☆☆

    Reprint requests: Alan Maisel, MD, VAMC Cardiology 111-A, 3350 La Jolla Village Dr., San Diego, CA 921161.

    4/1/83871

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