Home Therapies in Advanced Heart Failure: Inotropes and Diuretics
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ETHICS/PALLIATIVE CARE (S FEDSON, SECTION EDITOR)
Home Therapies in Advanced Heart Failure: Inotropes and Diuretics Jason P. Graffagnino 1,2 & Leslie C. Avant 1,2 & Bethany C. Calkins 3 & Keith M. Swetz 1,2
# This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020
Abstract Purpose of Review Heart failure (HF) is a significant cause of morbidity, mortality, and decreased quality of life (QOL). Symptoms, including reduced activity tolerance, fatigue, palpitations, and dyspnea, result from volume overload or low output states. Herein, we review the best available literature supporting diuretic and inotropic therapies in advanced HF and how these improve QOL. Recent Findings While diuretics and inotropes reduce symptoms and hospitalizations in advanced HF, there is an increased risk of harms with both modalities. While diuretic complications include electrolyte and renal function abnormalities, adverse event data with inotropes is more complex and includes possible arrhythmias and death. Further, inotrope utilization is complicated by required intravenous access, infusion costs, and limited outpatient support. Summary Ambulatory use of diuretics and inotropes may improve patients’ QOL through symptom management and reduced hospitalizations. However, risks and limitations of both modalities must be considered as treatment decisions are made. Keywords Palliative care, inotropes . Diuretics . Dyspnea . Advanced heart failure
Introduction Heart failure (HF) affects over 6 million American adults, with 8 million projected by 2030, and many more diagnosed worldwide [1]. Patients with advanced heart failure (AHF), classified as American College of Cardiology and American Heart Association (ACC/AHA) Stage D, have persistent severe symptoms despite aggressive and goal directed medical therapy [2]. Though these patients may be candidates for advanced therapies such as heart transplantation, resynchronization therapy, or mechanical circulatory support (namely, left ventricular assist devices [LVAD]), many patients do not qualify for, nor desire, such interventions. In these instances, optimizing quality of life (QOL) by avoiding invasive interventions and recurrent This article is part of the Topical Collection on Ethics/Palliative Care * Keith M. Swetz [email protected] 1
Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
2
Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
3
Western New York Veterans Affairs Medical Center, Department of Medicine, Jacobs School of Medicine at University of Buffalo, Buffalo, NY, USA
hospitalization is often the goal of therapy. As such, managing symptoms when the underlying problem cannot be durably remedied becomes essential. HF is a complex pathophysiologic state that results from the heart’s inability to pump blood effectively to perfuse the rest of the body. To compensate, the body uses mechanisms to expand intravascular volume to increase mean arterial pressure. However, thes
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