Key result
Continuing medical education has shifted from traditional instruction to facilitating practice-based learning through self-directed curriculums, group interaction, and organizational learning.
Why the study?
Does inotrope use within 24 hours of hospital presentation affect all-cause death in patients admitted for heart failure?
Does inotrope use within 24 hours of hospital presentation affect all-cause death in patients admitted for heart failure?
Inotrope use in heart failure patients without hypotension or hypoperfusion is associated with a significantly increased risk of long-term all-cause mortality.
Inotrope use without hypotension may raise long-term mortality in acute HF; leaves open causal confirmation by RCTs.
Objectives Current guidelines restrict the use of inotropes for the treatment for heart failure (HF) unless the patients are hypotensive or hypoperfused because of safety concerns. This study sought to characterise the contemporary real-world use of inotropes and associated long-term outcomes according to systolic blood pressure (sBP) and perfusion status. Design A multicentre prospective cohort study. Setting This study was nested from the Kyoto Congestive Heart Failure registry, which included consecutive Japanese patients admitted for HF. Participants We categorised 3995 patients into two groups: sBP ≥90 mm Hg and warm profile group, and sBP <90 mm Hg or cold profile group. In each group, patients were stratified across the use of inotropes within 24 hours of hospital presentation. Primary and secondary outcomes The primary outcome was all-cause death throughout follow-up. Secondary outcomes included cardiovascular death throughout follow-up, all-cause death during index hospitalisation and after discharge, and HF hospitalisation. Results A total of 793 patients (20%) presented with sBP <90 mm Hg or cold profile, whereas 3202 patients had sBP ≥90 mm Hg and warm profile; 276 patients (35%) in the sBP <90 mm Hg/cold group and 312 patients (10%) in the sBP ≥90 mm Hg/warm group received initial inotropic treatment. Adjusted excess risk of inotrope use relative to no inotrope for the primary outcome measure was significant in the sBP ≥90 mm Hg/warm group (adjusted HR), 1.36; 95% CI 1.09 to 1.72, p=0.006) but not in the sBP <90 mm Hg/cold group (adjusted HR, 1.28, 95% CI 0.96 to 1.69, p=0.09). Risk for postdischarge all-cause death and HF hospitalisation was not significantly different between the patients with inotropes and no inotropes in both groups. Conclusion Inotrope use in the absence of hypotension and hypoperfusion is still common, but associated with a worse long-term prognosis. Trial registration number UMIN000015238.
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Fox et al. (1998) conducted a review in Continuing medical education. Continuing medical education (CME) was evaluated. Continuing medical education has shifted from traditional instruction to facilitating practice-based learning through self-directed curriculums, group interaction, and organizational learning.
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