Effects of Widespread Inotrope Use in Acute Heart Failure Patients

Current guidelines recommend that inotropes should not be used in patients with normal systolic blood pressure (SBP). However, this is not supported with concrete evidence. We aimed to evaluate the effect of inotropes in acute heart failure (HF) patients from a nationwide HF registry. A total of 5625 patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. The primary outcomes were in-hospital adverse events and 1-month mortality. Among the total population, 1703 (31.1%) received inotropes during admission. Inotrope users had a higher event rate than non-users (in-hospital adverse events: 13.3% vs. 1.4%, p < 0.001; 1-month mortality: 5.5% vs. 2.5%, p < 0.001), while inotrope use was an independent predictor for clinical outcomes (in-hospital adverse events: ORadjusted 5.459, 95% CI 3.622–8.227, p < 0.001; 1-month mortality: HRadjusted 1.839, 95% CI 1.227–2.757, p = 0.003). Subgroup analysis showed that inotrope use was an independent predictor for detrimental outcomes only in patients with normal initial SBP (≥90 mmHg) (in-hospital adverse events: ORadjusted 5.931, 95% CI 3.864–9.104, p < 0.001; 1-month mortality: HRadjusted 3.584, 95% CI 1.280–10.037, p = 0.015), and a propensity score-matched population showed consistent results. Clinicians should be cautious with the usage of inotropes in acute heart failure patients, especially in those with a normal SBP.

1. Death due to Heart failure (HF) progression: Death occurring in the context of clinically worsening symptoms and/or signs of heart failure. New or worsening signs and/or symptoms of congestive HF may include any of the following:  New or increasing symptoms and/or signs of HF requiring the initiation of, or an increase in, treatment directed at HF or occurring in a patient already receiving maximal therapy for HF  HF symptoms or signs requiring continuous intravenous therapy or oxygen administration  Cardiogenic shock, manifested as clinical signs and symptoms of hypoperfusion felt to be secondary to cardiac dysfunction, and not occurring in the context of an acute myocardial infarction or as the consequence of a primary arrhythmic event Patients who are hospitalized and are being actively treated for HF and who have an arrhythmia as the terminal event will be classified as having a HF-related death.

Sudden cardiac death:
Death that occurs unexpectedly in a previously stable patie nt will be adjudicated as being sudden cardiac death. The death can be further catego rized as witnessed or unwitnessed: Witnessed sudden cardiac death:


Witnessed within 60 minutes of the onset of new or worsening cardiac symptoms  Witnessed and attributed to an identified arrhythmia (e.g., captured on an electrocardiographic (ECG) recording or witnessed on a monitor by either a medic or paramedic)  Subjects unsuccessfully resuscitated from cardiac arrest or successfully resuscitated from cardiac arrest but who die without identification of a non-cardiac etiology Note that if a witnessed sudden cardiac death occurs as a complication of another primary cardiac process, eg, cardiogenic shock or acute myocardial infarction, the primary process should be adjudicated as the cause of death.

Unwitnessed sudden cardiac death:
An unwitnessed death is one that occurs in a patient who when last seen alive within an observation period of 72 hours:  Did not manifest another life-threatening non-cardiac disease (e.g., infectious, metabolic disorders); and/or  Did not reveal a cause other than cardiovascular (e.g., trauma) at the scene of death; and/or  Death was ruled cardiovascular in cause on an autopsy report or death certificate, and occurred in the absence of pre-existing circulatory failure or other modes of death.

3.
Death due to Acute Coronary Syndrome: Death occurring up to 14 days after a d ocumented acute coronary syndrome and/or acute myocardial infarction and where t here is no conclusive evidence of another cause of death. If death occurs before bioch emical confirmation of myocardial necrosis can be obtained, adjudication should be b ased on clinical presentation and ECG evidence.

4.
Death due to Cerebrovascular Event: Death occurring up to 30 days after a suspe cted or confirmed stroke (ischemic stroke or hemorrhagic stroke) based on clinical sig ns and symptoms as well as neuroimaging and/or autopsy, and where there is no con clusive evidence of another cause of death.

5.
Death due to Other Cardiovascular Causes: Death must be due to a documented cardiovascular cause not included in the above categories (e.g., peripheral vascular d isease, systemic embolus, pulmonary embolism, cardiac procedure complication, and so on) 6. Death due to Non-Cardiovascular cause: Non-cardiovascular death is defined as any death not covered by cardiac death or vascular death Tables   Table S1. Specific diseases entity of the main underlying etiology of acute heart failure, ischemic heart disease.

Supplementary
In-hospital clinical events occurred in 280 (5.1%) of the cases during admission. Cardiac death occupied the majority of in-hospital clinical events (70.3%), and the most common cause of cardiac death was HF aggravation (60.4%). In subgroup analysis, cardiac death was more common in inotrope users (