title: Care processes and clinical outcomes of continuous outpatient support with inotropes (COSI) in patients with refractory endstage heart failure.
abstract: BACKGROUND
  This study describes the process and outcomes of continuous outpatient support with inotropes (COSI) in patients with Stage D heart failure (HF). Although Stage D HF has recently been defined as end-stage disease requiring special interventions for survival such as COSI or ventricular assist devices, concern has been raised regarding the safety, efficacy, mortality outcomes, and ethics of COSI.
  
  
  RESULTS
  Inotrope dependence was defined as worsening of the patient's clinical status with attempted inotrope withdrawal such that the patient was deemed unlikely to survive to permit hospital discharge. A care process for COSI was designed; baseline and outcome variables were evaluated. COSI was administered to 36 inotrope-dependent patients (age 55.4 +/- 9.5 years, 24 males). Baseline characteristics (mean +/- SD) were consistent with Stage D HF: left ventricular ejection fraction 19.9 +/- 8.5, left ventricular end-diastolic dimension (LVEDD) 70 +/- 10 mm, systolic blood pressure 97.4 +/- 13.4 mm Hg, serum creatinine 1.5 +/- 0.6, serum sodium 131.7 +/- 5.3; 69 HF hospitalizations (mean 1.9 +/- 1.8) 6 months before COSI initiation. Symptomatic hypotension, increasing dyspnea, renal dysfunction, and hypoperfusion most commonly prevented inotrope withdrawal. Despite Stage D HF, patients were discharged with COSI ambulatory, oriented, and pain free. Rehospitalizations were 46; 6 subjects accounted for 24 hospitalizations; 23 had 0 or 1 rehospitalization. Median survival was 3.4 months (range 0.2-26.3 months); and 3-, 6-, and 12-month Kaplan Meier survival was 51%, 26%, and 6%, respectively. The majority of patients died at home and chose to not undergo resuscitation attempts.
  
  
  CONCLUSIONS
  COSI may be an acceptable treatment option for Stage D HF.
authors.affiliation: Department of Medicine/Cardiology, Oregon Health & Science University, Portland, Oregon 97239, USA.
authors.forename: Ray E
authors.initials: RE
authors.lastname: Hershberger
authors.forename: Deirdre
authors.initials: D
authors.lastname: Nauman
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Walker
authors.forename: Diana
authors.initials: D
authors.lastname: Dutton
authors.forename: Donna
authors.initials: D
authors.lastname: Burgess
mesh_terms: D000553:Ambulatory Care; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D012449:Safety; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D002316:Cardiotonic Agents