Outcomes associated with vasoactive therapy in patients with acute decompensated heart failure.
OBJECTIVE
To describe the clinical management of acute decompensated heart failure (ADHF) in patients receiving intravenous treatment with dobutamine, milrinone, or nesiritide, and to evaluate differences, based on treatment received, in the in-hospital mortality rate, length of stay (LOS), total health care costs, and 30-day hospital readmission rate.


METHODS
Retrospective cohort analysis.


METHODS
University HealthSystem Consortium (UHC) Clinical Database Pharmacy, a database with information from 32 academic hospitals.


METHODS
Two thousand one hundred thirty patients with ADHF who received dobutamine (1311 patients), milrinone (433), or nesiritide (386).


RESULTS
Patients with ADHF were categorized according to the vasoactive therapy received. To evaluate baseline characteristics, chi(2) analysis was used; logistic regression was employed to assess the relationships between drug therapy and in-hospital mortality rates, and multivariate linear regression was used to assess whether drug therapy was related to LOS and total health care costs. All regression analyses controlled for age, sex, race, region of the United States where the hospital was located, primary payer for the hospital stay, UHC patient severity class, and chronic renal failure. In-hospital mortality rates were 10.2%, 7.9%, and 2.9% in the dobutamine, milrinone, and nesiritide groups, respectively. This resulted in an adjusted odds ratio for death of 3.5 (95% confidence interval [CI] 1.8-6.8) for dobutamine and 3.9 (95% CI 1.8-8.3) for milrinone (p<0.0001). Compared with inotropic therapy (dobutamine and milrinone), mean LOS in the hospital and the intensive care unit were lower with nesiritide (p<0.001). Total health care costs were lowest with nesiritide, but this reached statistical significance only when compared with milrinone (p<0.001). Thirty-day hospital readmission rates with dobutamine, milrinone, and nesiritide were 5.0%, 9.5%, and 3.9%, respectively (p=NS).


CONCLUSIONS
Nesiritide therapy was associated with a lower in-hospital mortality rate and shorter LOS compared with dobutamine and milrinone. In addition, total health care costs with nesiritide were decreased compared with milrinone. These observations need to be validated by a randomized controlled trial.
Arnold
Lindsay M
LM
Department of Pharmacy, Boston Medical Center, Boston, Massachusetts, USA.
Crouch
Michael A
MA
Carroll
Norman V
NV
Oinonen
Michael J
MJ
D000208:Acute Disease; D000368:Aged; D002316:Cardiotonic Agents / Q000191:economics / Q000627:therapeutic use*; D015331:Cohort Studies; D004280:Dobutamine / Q000627:therapeutic use; D005260:Female; D017048:Health Care Costs; D006333:Heart Failure / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D020105:Milrinone / Q000627:therapeutic use; D045283:Natriuretic Agents / Q000191:economics / Q000627:therapeutic use*; D020097:Natriuretic Peptide, Brain / Q000627:therapeutic use; D016017:Odds Ratio; D010359:Patient Readmission; D012044:Regression Analysis; D012189:Retrospective Studies; D016896:Treatment Outcome
D002316:Cardiotonic Agents; D045283:Natriuretic Agents; D020097:Natriuretic Peptide, Brain; D004280:Dobutamine; D020105:Milrinone