The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Ambulatory Patients with Cardiometabolic Disease and Without Evidence of COVID-19 During the Pandemic. The CorCOVID LATAM Study.

Background: SARS-CoV-2 pandemic has modified the cardiovascular care of ambulatory patients. The aim of this survey was to study changes in lifestyle habits, treatment adherence, and mental health status in patients with cardiometabolic disease, but no clinical evidence of COVID-19. Methods: A cross-sectional survey was conducted in ambulatory patients with cardiometabolic disease using paper/digital surveys. Variables investigated included socioeconomic status, physical activity, diet, tobacco use, alcohol intake, treatment discontinuation, and psychological symptoms. Results: A total of 4,216 patients (50.9% males, mean age 60.3 ± 15.3 years old) from 13 Spanish-speaking Latin American countries were enrolled. Among the study population, 46.4% of patients did not have contact with a healthcare provider, 31.5% reported access barriers to treatments and 17% discontinued some medication. Multivariate analysis showed that non-adherence to treatment was more prevalent in the secondary prevention group: peripheral vascular disease (OR 1.55, CI 1.08-2.24; p = 0.018), heart failure (OR 1.36, CI 1.05-1.75; p = 0.017), and coronary artery disease (OR 1.29 CI 1.04-1.60; p = 0.018). No physical activity was reported by 38% of patients. Only 15% of patients met minimum recommendations of physical activity (more than 150 minutes/week) and vegetable and fruit intake. Low/very low income (45.5%) was associated with a lower level of physical activity (p < 0.0001), less fruit and vegetables intake (p < 0.0001), more tobacco use (p < 0.001) and perception of depression (p < 0.001). Low educational level was also associated with the perception of depression (OR 1.46, CI 1.26-1.70; p < 0.01). Conclusions: Patients with cardiometabolic disease but without clinical evidence of COVID-19 showed significant medication non-adherence, especially in secondary prevention patients. Deterioration in lifestyle habits and appearance of depressive symptoms during the pandemic were frequent and related to socioeconomic status.

Neglected Tropical Diseases and Other Infectious Diseases Affecting the Heart. The NET-Heart Project: Rationale and Design.

Introduction: Neglected tropical diseases (NTDs) are a group of infections that are prevalent in many of the tropical and sub-tropical developing countries where poverty is rampant. NTDs have remained largely unnoticed in the global health agenda. There is a substantial gap between the burden of disease for NTDs in cardiovascular diseases (CVD) and research devoted to the affected populations. We created a Latin-American initiative with emerging leaders (EL) from the Interamerican Society of Cardiology (IASC) with the objective to perform multiple systematic reviews of NTDs and other infectious diseases affecting the heart: The NET-Heart Project. Objective: To describe the rationale and design considerations of the NET-Heart project. Methods: The NET-Heart Project is a collaborative work of the IASC EL program. The main objective of the NET-Heart project is to systematically evaluate the available evidence of NTDs and other infectious diseases and their cardiovascular involvement. As a secondary objective, this initiative aims to offer recommendations and potential diagnostic and therapeutic algorithms that can aid the management of cardiovascular complications of these infectious diseases. After an expert discussion 17 initial infectious diseases were selected, for each disease we created one working group. The project was structured in different phases: Systematic review, brainstorming workshops, analysis and results, manuscript writing and recommendations and evaluation of clinical implications. Conclusion: The NET-Heart project is an innovative collaborative initiative created to assess burden and impact of NTDs and other infectious diseases in CVD. NTDs can no longer be ignored and must be prioritised on the health and research agenda. This project aims to review in depth the evidence regarding cardiac compromise of these serious conditions and to propose strategies to overcome barriers for efficient diagnosis and treatment of cardiovascular complications.

Cost-utility analysis of an implantable cardioverterdefibrillator for the treatment of patients with ischemic or non-ischemic New York Heart Association class II or III heart failure in Colombia / Análisis de costo-utilidad del desfibrilador cardioversor implantable para el tratamiento de pacientes colombianos con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association

INTRODUCTION: The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. OBJECTIVE: To determine the cost-utility relationship of an implantable cardioverter-defibrillator compared to optimal pharmacological therapy for patients with ischemic or non-ischemic New York Heart Association class II or III (NYHA II-III) heart failure in Colombia. MATERIALS AND METHODS: We developed a Markov model including costs, effectiveness, and quality of life from the perspective of the Colombian health system. For the baseline case, we adopted a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. We calculated the costs by consulting with the manufacturers of the device offered in the Colombian market and using national-level pricing manuals. We conducted probabilistic and deterministic sensitivity analyses. RESULTS: In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was USD$ 13,187 per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (USD$ 19,139 in 2017), the device would be a cost-effective strategy for the Colombian health system. However, the result may change according to the time horizon, the probability of death, and the price of the device. CONCLUSIONS: The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure would be a cost-effective strategy for Colombia. The results should be examined considering the uncertainty.

Introducción. El uso del desfibrilador cardioversor implantable reduce la probabilidad de muerte súbita en pacientes con insuficiencia cardíaca. Objetivo. Determinar la relación de costo-utilidad de un desfibrilador cardioversor implantable comparado con la terapia farmacológica óptima para pacientes con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association (NYHA II-III) en Colombia. Materiales y métodos. Se desarrolló un modelo de Markov que incluyó los costos, la efectividad y la calidad de vida desde la perspectiva del sistema de salud colombiano. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y de una 3,5 % para los beneficios. Las probabilidades de transición se obtuvieron de una revisión sistemática de la literatura. Los años de vida ajustados por calidad se usaron como resultado de salud. Para estimar los costos unitarios se usaron manuales tarifarios nacionales y, para los costos del dispositivo, se consultó a los fabricantes que lo comercializan en el mercado colombiano. Se hicieron análisis de sensibilidad probabilísticos y determinísticos. Resultados. En el caso base el costo adicional por año de vida ajustado por calidad ganado con el desfibrilador cardioversor implantable fue de USD$ 13,187. Usando un umbral de tres veces el producto interno bruto per cápita como referencia (USD$ 19.139 en 2017), el dispositivo sería costo-efectivo para el sistema de salud colombiano. Sin embargo, este resultado depende del horizonte temporal, de la probabilidad de muerte y del precio del dispositivo. Conclusiones. El uso de un desfibrilador cardioversor implantable sería una estrategia costo-efectiva para Colombia, aunque los resultados deben examinarse teniendo en cuenta la incertidumbre.

Cost-utility analysis of an implantable cardioverterdefibrillator for the treatment of patients with ischemic or non-ischemic New York Heart Association class II or III heart failure in Colombia / Análisis de costo-utilidad del desfibrilador cardioversor implantable para el tratamiento de pacientes colombianos con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association

Abstract Introduction: The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. Objective: To determine the cost-utility relationship of an implantable cardioverterdefibrillator compared to optimal pharmacological therapy for patients with ischemic or nonischemic New York Heart Association class II or III (NYHA II-III) heart failure in Colombia. Materials and methods: We developed a Markov model including costs, effectiveness, and quality of life from the perspective of the Colombian health system. For the baseline case, we adopted a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. We calculated the costs by consulting with the manufacturers of the device offered in the Colombian market and using national-level pricing manuals. We conducted probabilistic and deterministic sensitivity analyses. Results: In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was USD$ 13,187 per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (USD$ 19,139 in 2017), the device would be a cost-effective strategy for the Colombian health system. However, the result may change according to the time horizon, the probability of death, and the price of the device. Conclusions: The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure would be a cost-effective strategy for Colombia. The results should be examined considering the uncertainty

Resumen Introducción. El uso del desfibrilador cardioversor implantable reduce la probabilidad de muerte súbita en pacientes con insuficiencia cardíaca. Objetivo. Determinar la relación de costo-utilidad de un desfibrilador cardioversor implantable comparado con la terapia farmacológica óptima para pacientes con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association (NYHA II-III) en Colombia. Materiales y métodos. Se desarrolló un modelo de Markov que incluyó los costos, la efectividad y la calidad de vida desde la perspectiva del sistema de salud colombiano. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y de una 3,5 % para los beneficios. Las probabilidades de transición se obtuvieron de una revisión sistemática de la literatura. Los años de vida ajustados por calidad se usaron como resultado de salud. Para estimar los costos unitarios se usaron manuales tarifarios nacionales y, para los costos del dispositivo, se consultó a los fabricantes que lo comercializan en el mercado colombiano. Se hicieron análisis de sensibilidad probabilísticos y determinísticos. Resultados. En el caso base el costo adicional por año de vida ajustado por calidad ganado con el desfibrilador cardioversor implantable fue de USD$ 13,187. Usando un umbral de tres veces el producto interno bruto per cápita como referencia (USD$ 19.139 en 2017), el dispositivo sería costo-efectivo para el sistema de salud colombiano. Sin embargo, este resultado depende del horizonte temporal, de la probabilidad de muerte y del precio del dispositivo. Conclusiones. El uso de un desfibrilador cardioversor implantable sería una estrategia costo-efectiva para Colombia, aunque los resultados deben examinarse teniendo en cuenta la incertidumbre.

Impacto clínico de un programa de falla cardiaca / Clinical impact of heart failure program

Introducción: La falla cardiaca es un problema de salud pública, genera grandes costos al sistema de salud por las readmisiones hospitalarias y genera morbimortalidad en los pacientes. Objetivo: Evaluar el impacto en la clase funcional, las visitas al servicio de urgencias y las readmisiones hospitalarias en la población de pacientes atendidos en el programa de falla cardiaca de un centro de referencia cardiovascular en Colombia. Metodología: Estudio de cohorte retrospectivo y prospectivo. Se realizó un análisis de las características clínicas y demográficas de los pacientes un año antes y después de ingresar al programa de la falla cardiaca. Resultados: Se incluyeron 511 pacientes, con una edad promedio de 66,4 ± 14,3 años, 58,7% de sexo masculino. Se realizó seguimiento en un programa de la falla cardiaca en el cual se contó con los controles por cardiología y enfermería, rehabilitación cardiaca, asistencia a un programa educativo y apoyo por psicología. Luego de 18 meses de seguimiento se demostró un incremento estadísticamente significativo en la fracción de eyección en la clase funcional, se disminuyeron las consultas a urgencias en un 29,3%, las rehospitalizaciones en un 66,8% y la duración de estas en un 37,5%. La mortalidad total fue del 4%. Conclusión: El seguimiento multidisciplinario en programas de la falla cardiaca es factible en Colombia, mejorando la clase funcional, la fracción de eyección y disminuyendo los ingresos hospitalarios y las visitas al servicio de urgencias.

Introduction: Heart failure is a public health problem. It generates morbidity in patients, hospital re-admissions and with huge costs to the health system. Objective: To evaluate the impact on functional class, visits to the emergency room, and hospital readmissions in the population of patients treated in a heart failure program of a reference cardiovascular centre in Colombia. Methodology: A retrospective and prospective cohort study was performed. The clinical, demographic characteristics of the patients, admissions to the hospital, emergency room visits, and the costs inherent to their care were analysed one year before and after they were admitted to the heart failure program. Results: A total of 511 patients were included, with a mean age of 66.4 +/- 14.3 years, 58.7% of whom were male. The follow up in the heart failure program included cardiology consultation, nurse evaluations, cardiac rehabilitation, an educational program, and psychological support. After 18 months of follow up, a statistically significant increase in ejection fraction was found in functional class. Emergency room visits decreased by 29.3%, admissions to the hospital decreased by 66.8%, and the length of stay decreased by 37.5. Total mortality was 4%. Conclusion: The multidisciplinary follow up in a heart failure program is feasible in Colombia. It improves the functional class, the ejection fraction, and decreases hospital readmissions and emergency room visits.

Cost-effectiveness analysis of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome in Colombia / Análisis de costo-efectividad del ticagrelor en comparación con el clopidogrel para el tratamiento de pacientes con síndrome coronario agudo en Colombia

Introduction: Acute coronary syndrome is one of the most frequent medical emergencies in developing countries. Objective: To determine, from the perspective of the Colombian health system, the cost-effectiveness of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome. Materials and methods: We conducted a cost-effectiveness analysis from the perspective of the Colombian health system comparing ticagrelor and clopidogrel for the treatment of patients with acute coronary syndrome. To estimate the expected costs and outcomes, a Markov model was constructed in which patients could remain stable without experiencing new cardiovascular events, suffer from a new event, or die. For the baseline case, a 10-year time horizon and a discount ratio of 3% for costs and benefits were adopted. The transition probabilities were extracted from the PLATO (Platelet Inhibition and Patient Outcomes) clinical trial. Vital statistics were drawn from the Departmento Administrativo Nacional de Estadística (DANE) and additional information from Colombian patients included in the Access registry. To identify and measure resource use, a standard case was built by consulting guidelines and protocols. Unit costs were obtained from Colombian rate lists. A probabilistic sensitivity analysis was conducted in which costs were represented by a triangular distribution, and the effectiveness through a beta distribution. Results: In the base case, the additional cost per quality-adjusted life-year gained with ticagrelor was COP$ 28,411,503. The results were sensitive to changes in the time horizon and the unit cost of clopidogrel. For a willingness-to-pay equivalent to three times the Colombian per capita gross domestic product, the probability of ticagrelor being cost-effective was 75%. Conclusions: Ticagrelor is a cost-effective strategy for the treatment of patients with acute coronary syndrome in Colombia.

Introducción. El síndrome coronario agudo es una de las emergencias médicas más frecuentes en los países en desarrollo. Objetivo. Determinar, desde la perspectiva del sistema de salud colombiano, la relación de costo-efectividad del ticagrelor comparado con el clopidogrel para el tratamiento de pacientes con síndrome coronario agudo. Materiales y métodos. Se hizo un análisis de costo-efectividad desde la perspectiva del sistema de salud colombiano, comparando el ticagrelor y el clopidogrel para el tratamiento de pacientes con síndrome coronario agudo. Para estimar los costos y resultados esperados de las dos alternativas, se construyó un modelo de Markov en el cual los pacientes podían permanecer estables sin experimentar nuevos eventos cardiovasculares, sufrir de un nuevo evento coronario o morir. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y beneficios. Las probabilidades de transición se extrajeron del estudio Platelet Inhibition and Patient Outcomes , PLATO. Las estadísticas vitales se consultaron en informes del Departamento Administrativo Nacional de Estadística (DANE) y los parámetros adicionales del modelo se basaron en la información de los pacientes colombianos incluidos en el registro en Access. Para identificar y medir el uso de recursos, se construyó un caso estándar a partir de guías y protocolos. Los costos unitarios se obtuvieron de manuales tarifarios colombianos. Se hizo un análisis de sensibilidad probabilístico en el que los costos se representaron por una distribución triangular y, las probabilidades de transición, mediante una distribución beta. Resultados. En el caso de base, el costo adicional por años de vida ajustados por calidad ganados con el ticagrelor fue de COP$ 28´411.503. Los resultados fueron sensibles a los cambios en el horizonte temporal y al costo unitario del clopidogrel. Para un umbral de costo-efectividad equivalente a tres veces el producto interno bruto per cápita de Colombia, la probabilidad de que el ticagrelor fuera costo-efectivo fue de 75 %. Conclusiones. El ticagrelor es una estrategia costo-efectiva para el tratamiento de los pacientes con síndrome coronario agudo en Colombia.

Análisis de costo efectividad de prasugrel, comparado con clopidogrel para pacientes con síndrome coronario agudo sometidos a intervención coronaria percutánea en Colombia / Analysis of cost effectiveness of prasugrel compared with clopidogrel for patients with acute coronary syndrome undergoing percutaneous coronary intervention in Colombia

Objetivo: determinar, desde la perspectiva del sistema de salud colombiano, la relación de costo-efectividad del prasugrel comparado con clopidogrel, para el tratamiento de pacientes adultos con síndrome coronario agudo. Material y métodos: se construyó un modelo de Markov con ciclos anuales en el cual los pacientes pueden permanecer sin experimentar nuevos eventos cardiovasculares, sufrir un nuevo evento o morir. En el caso base se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3%. Las probabilidades de transición se extrajeron del ensayo clínico TRITON-TIMI 38, de las estadísticas vitales del Departamento Nacional de Estadística y de la información de los pacientes colombianos del registro ACCESS. Para identificar y medir el uso de recursos se diseñó un caso típico a partir de la revisión de guías y protocolos; para la valoración se emplearon manuales tarifarios colombianos. Se realizaron análisis de sensibilidad determinísticos y probabilísticos. Resultados: en el caso base, el costo por año de vida ajustado por calidad ganado con prasugrel es $79 987 695 pesos colombianos. Los resultados son sensibles a cambios en el horizonte temporal y al costo del clopidogrel. Bajo un umbral de disposición a pagar de tres veces el PIB per cápita colombiano, la probabilidad de que el prasugrel sea costo efectivo es 7%. Conclusiones: la decisión respecto a la inclusión del prasugrel en el tratamiento de pacientes con síndrome coronario agudo, sometidos a intervención coronaria percutánea depende fundamentalmente del costo del clopidogrel que el decisor considere relevante para realizar la comparación. (Acta Med Colomb 2015; 40: 310-317).

Objective: to determine the cost-effectiveness relation of prasugrel compared with clopidogrel for the treatment of adult patients with acute coronary syndrome from the perspective of Colombian health system. Material and methods: a Markov model with annual cycles in which patients can remain without experiencing new cardiovascular events, have a new event or die, was built. In the base case a time horizon of 10 years and a discount rate of 3% was adopted. Transition probabilities were taken from the clinical trial TRITON-TIMI 38, of vital statistics from the National Department of Statistics and from the information of Colombian patients in ACCESS registry. To identify and measure the use of resources, a typical case was designed from the review of guidelines and protocols; Colombian tariff manuals were used for assessment. Deterministic and probabilistic sensitivity analyzes were performed. Results: in the base case, the cost per year of quality-adjusted life gained with prasugrel is $ 79,987,695 Colombian pesos. The results are sensitive to changes in the timeframe and cost of clopidogrel. Under a threshold willingness to pay three times the per capita GDP of Colombia, the probability that prasugrel may be cost-effective, is 7%. Conclusions: the decision on the inclusion of prasugrel in the treatment of patients with acute coronary syndrome undergoing percutaneous coronary intervention depends mainly on the cost of clopidogrel that the decision maker considers relevant to perform the comparison. (Acta Med Colomb 2015; 40: 310-317).

Cost-effectiveness analysis of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome in Colombia.

INTRODUCTION: Acute coronary syndrome is one of the most frequent medical emergencies in developing countries. OBJECTIVE: To determine, from the perspective of the Colombian health system, the cost-effectiveness of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome. MATERIALS AND METHODS: We conducted a cost-effectiveness analysis from the perspective of the Colombian health system comparing ticagrelor and clopidogrel for the treatment of patients with acute coronary syndrome. To estimate the expected costs and outcomes, a Markov model was constructed in which patients could remain stable without experiencing new cardiovascular events, suffer from a new event, or die. For the baseline case, a 10-year time horizon and a discount ratio of 3% for costs and benefits were adopted. The transition probabilities were extracted from the PLATO (Platelet Inhibition and Patient Outcomes) clinical trial. Vital statistics were drawn from the Departmento Administrativo Nacional de Estadística (DANE) and additional information from Colombian patients included in the Access registry. To identify and measure resource use, a standard case was built by consulting guidelines and protocols. Unit costs were obtained from Colombian rate lists. A probabilistic sensitivity analysis was conducted in which costs were represented by a triangular distribution, and the effectiveness through a beta distribution. RESULTS: In the base case, the additional cost per quality-adjusted life-year gained with ticagrelor was COP$ 28,411,503. The results were sensitive to changes in the time horizon and the unit cost of clopidogrel. For a willingness-to-pay equivalent to three times the Colombian per capita gross domestic product, the probability of ticagrelor being cost-effective was 75%. CONCLUSIONS: Ticagrelor is a cost-effective strategy for the treatment of patients with acute coronary syndrome in Colombia.

Comparative costs of home positive inotropic infusion versus in-hospital care in patients awaiting cardiac transplantation.

BACKGROUND: Outpatient positive inotropic support combined with implantation of an automatic implantable cardioverter defibrillator (AICD) may be used as a successful bridge to cardiac transplantation in patients with end-stage heart failure. A detailed comparative cost analysis of this outpatient strategy versus in-hospital care has not been previously reported. METHODS AND RESULTS: Twenty-one United Network for Organ Sharing 1B patients awaiting cardiac transplantation received continuous outpatient inotropic therapy for a total of 3070 patient-days. Daily costs for outpatient and in-hospital treatment were calculated. Nonparametric decision analysis was used to determine the strategy with greatest cost savings (immediate hospital discharge after AICD implantation versus in-hospital care). A threshold analysis was performed to test the robustness of the decision analysis model. The outpatient strategy realized an average savings of $71,300 to $120,500 per patient. Decision analysis showed that no fixed period of in-hospital monitoring was more cost-saving than immediate hospital discharge after AICD implantation. Threshold analysis revealed that AICD costs would need to exceed $82,000 (currently $62,000) or that the difference between the outpatient and the in-hospital costs would need to be < or = $475 per day for any other intermediate strategy to be considered cost-saving. CONCLUSION: Outpatient inotropic therapy combined with AICD implantation in selected patients awaiting cardiac transplantation is an effective cost-minimizing strategy.

Home continuous positive inotropic infusion as a bridge to cardiac transplantation in patients with end-stage heart failure.

BACKGROUND: The clinical use of positive inotropic therapy at home in patients awaiting cardiac transplantation has not been reported since United Network for Organ Sharing (UNOS) regulations were changed to allow home infusions in Status 1B patients. METHODS: We observed 21 consecutive patients with UNOS 1B status during positive inotropic therapy at home. We used hemodynamic monitoring at the initiation of therapy to optimize dosing. We selected for home therapy patients with stable clinical status and improved functional capacity during inotropic treatment. Implantable cardioverter defibrillators were placed in all but 1 patient before discharge. RESULTS: Initial positive inotropic therapy included dobutamine in 12 patients (mean dose, 4.5 mcg/kg/min; range, 2.5-7.5 mcg/kg/min), milrinone in 8 patients (mean dose, 0.44 mcg/kg/min; range, 0.375-0.55 mcg/kg/min), and dopamine at a dose of 3 mcg/kg/min in 1 patient. Patients had improved functional capacity (New York Heart Association Class 3.7 +/- 0.1 to 2.4 +/- 0.2, p < 0.01), improved renal function (serum creatinine, 1.5 +/- 0.1 to 1.3 +/- 0.1, p < 0.01), improved resting hemodynamics, and decreased number of hospitalizations during positive inotropic infusion therapy when compared with pre-treatment baseline. Implantable cardioverter defibrillator discharges were infrequent (0.19 per 100 patient days of follow-up). Actuarial survival to transplantation at 6 and 12 months was 84%. CONCLUSIONS: Continuous positive inotropic therapy at home was safe and was associated with decreased health care costs in selected patients awaiting cardiac transplantation.