Abstract

Background: Ambulatory inotropic infusions can be used as a palliative therapy (PT) or bridge to advanced therapies in end-stage heart failure (ESHF) patients, many of whom have implantable cardioverter defibrillators (ICDs). Research Questions: How often do patients receive ICD therapies after initiation of outpatient inotropic support and how often is defibrillation inactivated? Methods: We conducted a retrospective review of all patients discharged from an academic tertiary medical center with a new prescription for inotropic therapy between November 2017 and March 2023. Clinical data, Palliative Care consultation, and ICD interrogations before and after inotrope initiation were extracted from the electronic health record. Results: The cohort comprised 45 patients discharged on new inotropic support, including 22 (49%) with intent of PT and 23 (51%) as a bridge to advanced therapies (Figure). Among PT patients, 15 (68%) had an ICD in place with only 4 having ICD therapies deactivated at discharge. Only 2 additional PT patients had a documented discussion regarding ongoing ICD therapies. By 1 year, 4 (18%) PT patients were transitioned to hospice and 13 (59%) had died, with only 1 additional patient having ICD deactivation. Of 28 patients discharged on inotropic infusions with ICD therapies on (both PT and bridge patients), only 4 patients had ICD therapies turned off later and no ICD shocks were reported for the year following initiation of inotropic support. Conclusion: In a series of 45 patients initiated on inotropic support for PT or bridge to advanced therapies, the majority (77%) had an active ICD, but therapies were rarely delivered. Notably, there were very few documented discussions regarding ICD therapies in PT patients even with specialty Palliative Care consultation. In patients with ESHF initiated on inotropic support as PT, most patients chose to leave ICD therapies in place. For those patients, there was a low rate of ICD therapies delivered.