Background for Fast Fact #283    Some patients with symptoms at rest from end-stage heart failure (HF) are placed on continuous infusions of cardiac inotropes to relieve symptom distress and avoid hospitalizations. Among end-stage HF patients who are ineligible for advanced cardiac therapies (such as heart transplant of a ventricular assist device), mean life expectancy with inotrope-dependence is estimated at 9.4 months, with 26% surviving to 1 year (1). The home use of continuous inotrope therapy may be commonly encountered by clinicians who care for the seriously ill. This Fast Fact provides a primer on the use of home inotropes in patients with advanced HF who are not eligible for advanced cardiac therapies.

Pharmacology     Both major classes of inotropic agents, adrenergic agonists (i.e. dopamine and dobutamine) and phosphodiesterase inhibitors (i.e. milrinone), increase muscle contractility by increasing available calcium levels within myocardial tissue via cAMP regulation (2).

Patient selection      Candidates for ambulatory inotrope infusions include those: 

• With New York Heart Association Class (NYHA) IV HF despite optimal medical and device therapies (e.g., biventricular pacemakers). NYHA IV essentially means symptoms like dyspnea at rest.
• Unable to wean from inotropic support in the inpatient setting or are too ill to attempt weaning (3,4).
• Without refractory ventricular tachycardia or life-threatening arrhythmias (5).
• Willingness to use a central line, infusion pump, and necessary monitoring (5).

Outcomes and risks Data related to quality-of-life, mortality risk, and complications such as arrhythmias, infections, and hospitalizations are limited (6-7). Early studies suggested an average survival of ~3 months for patients on outpatient inotrope infusions (8-10).  However, these findings predate modern treatments (including SGLT2 inhibitors such as empagliflozin) and prophylactic AICD use. More recent cohort studies suggest a mean survival of 9 months with an AICD shock risk of 17%, infection rate of 30%, and nearly 60% rehospitalization rate (11-12). Despite these risks, if the patient’s goal is to be at home, there is evidence that continuous outpatient inotrope infusion shifts the remaining survival time to a home setting through improvements in symptom control in well selected patients (9).

Practical concerns    Inotrope infusions are started during an inpatient hospitalization typically in an intensive care unit for dose titration and monitoring. Right heart catheterizations are usually needed to determine the pre-inotrope infusion cardiac index and whether there are meaningful improvements in cardiac parameters after the inotrope is administered. Patients require a central line (PICC line or Hickman catheter) and oversight by a specialized home care team. Regular outpatient evaluations by a clinician, in many cases a cardiologist, are involved for dose adjustments. Monitoring of serum electrolytes and renal function is often needed to anticipate necessary dosing changes and to prevent iatrogenic hypotension or arrhythmias should change in creatinine clearance occur.

Medicare coverage requirements are strict for home inotropes. This affects how they are used in the US. Below are the criteria that need to be met for outpatient inotrope therapy to be covered (5). 

1. Uncontrolled symptoms: dyspnea at rest despite optimal cardiac therapies.
2. Hemodynamic studies (obtained from right heart catheterization):
    a. Pre-infusion cardiac index ≤2.2 L/min/m² and/or PCWP ≥20 mmHg.
    b. Demonstrated improvement in these values after initiation of inotropes (e.g., ≥20% increase in cardiac index or decrease in      PCWP).
3. Documentation of symptomatic improvement (such as reduced dyspnea or increased diuresis).
4. Monitoring: regular assessment by a HF specialist every three months.  

Cost of these therapies varies significantly depending on choice of drug, duration of need, and insurance type. Older data suggests that Medicare spends an average of $64,152 per beneficiary for home milrinone but only $848 for home dobutamine (13).  However, that difference in cost between the two medications has likely narrowed more recently (14).

Home care and hospice   Many hospice and skilled nursing facilities will not accept patients on continuous inotrope infusions (especially in smaller or more rural based hospital systems) given the cost of medications and the need for advanced training for infusion maintenance and care (10,15). Some communities have specialized home-care agencies or programs for patients on home inotropes, which may or may not be part of a hospice program. Some hospice programs can facilitate short periods of inotrope use (a few days) under “general inpatient” (GIP) level or home hospice care if goals have been clarified prior to enrollment to facilitate family visitation or other specific life goals prior to discontinuation. Close collaboration with social workers and clinical pharmacists is recommended.

References 

1. Long EF, Swain GW, & Mangi AA. Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure. Circulation: Heart Failure. 2014; 7:470-478.
2. Felker GM, O’Connor CM. Inotropic therapy for heart failure: an evidence-based approach. Am. Heart J. 2001; 142(3):393–401.
3. Lewis EF. End of life care in advanced heart failure. Curr Treat Options Cardiovasc Med. 2011; 13(1):79–89.
4. Young JB, Moen EK. Outpatient parenteral inotropic therapy for advanced heart failure. J Heart Lung Transplant. 2000; 19(8 Suppl):S49–57.
5. Gorski LA. Positive inotropic drug infusions for patients with heart failure: current controversies and best practice. Hom Healthc Nurs. 2002; 20:244-53.
6. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. May 3 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012.
7. Lopez-Candales A, Vera T, Gibbons W, et al.  Symptomatic improvement in patients treated with intermittent infusion of inotropes: a double-blind placebo controlled pilot study. J Med 2002; 33:129-146.
8. Gheorghiade M, Gattis WA, Klein L. OPTIME in CHF trial: rethinking the use of inotropes in the management of worsening chronic heart failure resulting in hospitalization. Eur J Heart Fail. 2003 Jan;5(1):9–12.
9. Felker GM, Benza RL, Chandler AB, et al. Heart failure etiology and response to milrinone in decompensated heart failure: results from the OPTIME-CHF study. J Am Coll Cardiol. Mar 19 2003;41(6):997-1003. doi:10.1016/s0735-1097(02)02968-6.
10. Hershberger RE, Nauman D, Walker TL, Dutton D, Burgess D. Care processes and clinical outcomes of continuous outpatient support with inotropes (COSI) in patients with refractory endstage heart failure. J Card Fail. Jun 2003;9(3):180-7. doi:10.1054/jcaf.2003.24.
11. Acharya D, Sanam K, Revilla-Martinez M, et al. Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy. Am J Cardiol. Mar 15 2016;117(6):952-6. doi:10.1016/j.amjcard.2015.12.030.
12. Hashim T, Sanam K, Revilla-Martinez M, Morgan CJ, Tallaj JA, Pamboukian SV, Loyaga-Rendon RY, George JF, Acharya D. Clinical Characteristics and Outcomes of Intravenous Inotropic Therapy in Advanced Heart Failure. Circ Heart Fail. 2015 Sep;8(5):880-6.
13. Gilstrap  LG, DeFilippis  EM, Stevenson  LW.  An unintended consequence of the 21st-century Cures Act for patients with heart failure.  Circulation. 2017;136(2):123-125.
14. Chuzi S, Allen LA, Dunlay SM, et al.  Palliative inotrope therapy: a narrative review. JAMA Cardiol 2019; 4(8):815-22.
15. Groninger  H, Gilhuly  D, Walker  KA.  Getting to the heart of the matter: a regional survey of current hospice practices caring for patients with heart failure receiving advanced therapies.  Am J Hosp Palliat Care. 2019;36(1):55-59. http://circ.ahajournals.org/content/119/14/1977.

Authors’ Affiliations: Allegheny Health Network, Pittsburgh, PA.
Conflicts of Interest: The authors have disclosed no relevant conflicts of interest.
Version History:  First published August 2014. Reviewed and updated in September 2015 by Sean Marks MD; then again in February 2025 by Jamie Pfaff MD, Melanie Skelton MD, Sumi Misra MD, MPH.