Department of Medicine, University of Colorado at Denver, Denver, Colorado.
Division of Preventive, Occupational, and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
JACC Heart Fail. 2018 Sep;6(9):757-767. doi: 10.1016/j.jchf.2018.03.019. Epub 2018 Jul 11.
This study sought to systematically review the available evidence of risks and benefits of ambulatory intravenous inotrope therapy in advanced heart failure (HF).
Ambulatory inotrope infusions are sometimes offered to patients with advanced Stage D HF; however, an understanding of the relative risks and benefits is lacking.
On August 7, 2016, we searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for studies of long-term use of intravenous inotropes in outpatients with advanced HF. Meta-analysis was performed using random effects models.
A total of 66 studies (13 randomized controlled trials and 53 observational studies) met inclusion criteria. Most studies were small and at high risk for bias. Pooled rates of death (41 studies), all-cause hospitalization (15 studies), central line infection (13 studies), and implantable cardioverter-defibrillator shocks (3 studies) of inotropes were 4.2, 22.2, 3.6, and 2.4 per 100 person-months follow-up, respectively. Improvement in New York Heart Association (NYHA) functional class was greater in patients taking inotropes than in controls (mean difference of 0.60 NYHA functional classes; 95% confidence interval [CI]: 0.22 to 0.98; p = 0.001; 5 trials). There was no significant difference in mortality risk in those taking inotropes compared with controls (pooled risk ratio: 0.68; 95% CI: 0.40 to 1.17; p = 0.16; 9 trials). Data were too limited to pool for other outcomes or to stratify by indication (i.e., bridge-to-transplant or palliative).
High-quality evidence for the risks and benefits of ambulatory inotrope infusions in advanced HF is limited, particularly when used for palliation. Available data suggest that inotrope therapy improves NYHA functional class and does not impact survival.
本研究旨在系统地回顾静脉内正性肌力药物在晚期心力衰竭（HF）患者门诊应用的风险和获益证据。
对于晚期 D 期 HF 患者，有时会提供门诊正性肌力药物输注；然而，对其相对风险和获益的了解仍有所欠缺。
2016 年 8 月 7 日，我们在 SCOPUS、Web of Science、Ovid EMBASE 和 Ovid MEDLINE 中检索了长期静脉内正性肌力药物用于门诊晚期 HF 患者的研究。采用随机效应模型进行荟萃分析。
共有 66 项研究（13 项随机对照试验和 53 项观察性研究）符合纳入标准。大多数研究规模较小，存在高偏倚风险。正性肌力药物的死亡率（41 项研究）、全因住院率（15 项研究）、中心静脉感染率（13 项研究）和植入式心脏复律除颤器电击率（3 项研究）分别为每 100 人-月随访 4.2、22.2、3.6 和 2.4。与对照组相比，接受正性肌力药物治疗的患者 NYHA 心功能分级改善更大（平均差异 0.60 个 NYHA 心功能分级；95%置信区间 [CI]：0.22 至 0.98；p=0.001；5 项研究）。与对照组相比，接受正性肌力药物治疗的患者死亡率无显著差异（合并风险比：0.68；95%CI：0.40 至 1.17；p=0.16；9 项研究）。由于数据有限，无法汇总其他结局或按适应证（即桥接移植或姑息治疗）进行分层。
在晚期 HF 患者中，门诊应用正性肌力药物的风险和获益的高质量证据有限，特别是在姑息治疗中。现有数据表明，正性肌力药物治疗可改善 NYHA 心功能分级，不影响生存率。
