Table 6.8. Outpatient use of intravenous inotropes in patients with advanced HF who are not eligible for heart transplantation or mechanical circulatory support devices.

Recommendations	Class	LE	Comments	Table 2018	Ref.
Continuous outpatient intravenous inotrope therapy as palliative care for symptom control in advanced HF patients who are not eligible for mechanical circulatory support devices or heart transplantation.	IIb	C	NEW: The current recommendation reflects data from studies with limitations in design and execution.	New	76–78
Intermittent use of inotropes or inodilator to improve symptoms in advanced HF patients or palliative care in patients without other advanced therapy options.	IIb	B	NEW: New evidence from moderate-quality meta-analysis and RCT support the recommendation.	New	79
The evidence assessing the risks and benefits of palliative care with intravenous inotrope therapy on an outpatient basis for patients with advanced HF is limited, consisting primarily of observational studies without a control group. Meta-analyses of small randomized controlled trials and heterogeneous observational studies suggest a potential clinical benefit of continuous or intermittent outpatient inotrope therapy for patients with advanced HF who are not eligible for an MCSD or heart transplantation.76–78 Benefits include relief of symptoms and lower readmission rates. However, the need for a central catheter for continuous infusion of inotropes is associated with greater special care and risk of infections. The LION-HEART (Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure) pilot trial randomly assigned 69 patients with advanced HF to either placebo or intermittent levosimendan at a dosage of 0.2 ¼g/kg/min for 6 hours every 2 for 12 weeks and demonstrated the benefit of inotropic therapy in relation to lower plasma NT-proBNP levels, higher quality of life scores, and lower readmission rates, with no difference in rates of adverse events between groups.79 To date, there are no cost-effectiveness studies evaluating the impact of outpatient inotropic infusion as palliative therapy for patients with advanced HF.

HF: heart failure; NT: N-terminal portion of B-type natriuretic peptide; RCT: randomized controlled trial