What is the prognosis for an 87-year-old male with severe Heart Failure with reduced Ejection Fraction (HFrEF) and left ventricular dysfunction of 20%, requiring inotropic (inotropic) support every 2 weeks, and needing assistance with Activities of Daily Living (ADLs) if he were to discontinue inotropic support?

Prognosis After Discontinuing Inotropic Support in an 87-Year-Old with Stage D HFrEF

If this 87-year-old male with severe HFrEF (EF 20%) requiring inotropic support every 2 weeks discontinues inotropes, his prognosis is extremely poor with expected survival measured in days to weeks, not months. This patient has Stage D heart failure with inotrope dependence, which represents end-stage disease with the highest mortality risk 1.

Clinical Context and Disease Severity

This patient meets multiple criteria for Stage D heart failure 1:

• Severe left ventricular dysfunction (EF 20%) indicating profound systolic impairment
• Inotrope dependence requiring infusions every 2 weeks, demonstrating inability to maintain adequate perfusion without pharmacologic support
• Functional impairment requiring assistance with activities of daily living, indicating NYHA Class IV symptoms
• Advanced age (87 years) which compounds risk

The ACC/AHA guidelines explicitly classify dependence on continuous or intermittent intravenous inotropic support as a defining feature of Stage D heart failure, the most advanced stage with the worst prognosis 1.

Expected Outcomes After Inotrope Discontinuation

Immediate Hemodynamic Consequences

Withdrawal of inotropic support will result in rapid hemodynamic deterioration 1:

• Cardiac output will decline precipitously, as the heart cannot maintain adequate perfusion without pharmacologic augmentation
• End-organ hypoperfusion will develop, affecting kidneys, liver, brain, and other vital organs
• Cardiogenic shock is likely, given the patient's demonstrated dependence on inotropes to maintain systemic perfusion 1

Mortality Timeline

The 5-year survival rate after hospitalization for HFrEF is only 25%, but this patient's prognosis is far worse given inotrope dependence 2. While specific data on survival after inotrope withdrawal in Stage D heart failure is limited, the guidelines make clear that these patients require inotropic support precisely because they cannot maintain adequate perfusion without it 1.

Expected survival without inotropic support would likely be days to a few weeks at most, based on:

• The patient's demonstrated inability to maintain hemodynamic stability for more than 2 weeks between infusions
• The severity of left ventricular dysfunction (EF 20%)
• Advanced age limiting physiologic reserve
• Functional dependence indicating poor baseline status

Guideline Perspective on Inotrope Use in This Population

Current Indications

The 2022 AHA/ACC/HFSA guidelines acknowledge that inotropes do not improve survival and carry significant risks including arrhythmias and increased mortality 1. However, they remain indicated in specific circumstances 1:

Class IIb recommendation (may be considered): Long-term continuous intravenous inotropic support for palliative therapy in select patients with Stage D HF who are not candidates for mechanical circulatory support or transplantation 1.

Class III: Harm designation: Long-term use of continuous or intermittent intravenous inotropes is potentially harmful except for palliative care 1.

Why Inotropes Are Used Despite Harm

Despite improving hemodynamic compromise, positive inotropic agents have not demonstrated improved outcomes in heart failure 1. Regardless of mechanism (phosphodiesterase inhibition, adrenergic stimulation, calcium sensitization), chronic inotrope treatment increases mortality, mostly from arrhythmic events 1.

Parenteral inotropes remain an option only for patients refractory to all other therapies who are suffering end-organ hypoperfusion 1.

Complications Associated with Continued Inotrope Use

If inotropes were continued, this patient faces substantial risks 3:

• 17% risk of ICD shocks during follow-up, with 82% being appropriate shocks for ventricular tachycardia/ventricular fibrillation
• 29% risk of infections, most commonly bacteremia from indwelling catheters
• 57% risk of rehospitalization, with common causes being worsening heart failure (41%), infections (20%), and arrhythmias (12%)

Alternative Management Options

Mechanical Circulatory Support

This patient is likely NOT a candidate for mechanical circulatory support given his age and functional status 1. The guidelines indicate MCS is reasonable for carefully selected patients with Stage D HFrEF, but patient selection requires consideration of:

• Age and comorbidities (87 years is typically beyond consideration)
• Functional status and ability to participate in rehabilitation
• Social support and cognitive function
• Goals of care

Cardiac Transplantation

Cardiac transplantation is definitively not an option given the patient's age 1. Transplant evaluation is indicated for carefully selected patients with Stage D HF, but age 87 exceeds all transplant center criteria.

Palliative Care Approach

The most appropriate framework for this patient is palliative care with goals-of-care discussion 1. The guidelines explicitly recognize continuous intravenous inotropic support as palliative therapy for symptom control in select patients with Stage D HF who are not eligible for MCS or transplantation 1.

If the decision is made to discontinue inotropes, this should occur within a comprehensive palliative care framework that includes:

• Aggressive symptom management for dyspnea, pain, and anxiety
• Diuretics for comfort (not volume targets)
• Opioids for dyspnea and comfort
• Hospice referral for end-of-life care
• Family support and bereavement planning

Clinical Decision-Making Algorithm

For this specific patient, the decision pathway is:

1. Assess candidacy for advanced therapies (MCS or transplant):

   • Age 87 → Not a candidate 1
   • Functional dependence → Not a candidate 1

2. If not a candidate for advanced therapies, clarify goals of care:

   • If goal is comfort and quality of remaining life → Continue inotropes as palliative therapy 1
   • If patient/family wishes to discontinue aggressive measures → Transition to hospice with inotrope discontinuation 1

3. If discontinuing inotropes:

   • Expect survival of days to weeks based on demonstrated inotrope dependence
   • Implement comprehensive palliative care with aggressive symptom management
   • Provide hospice-level support for patient and family 1

Common Pitfalls to Avoid

Do not discontinue inotropes without a comprehensive palliative care plan in place 1. The patient will experience significant symptoms including dyspnea, anxiety, and discomfort as cardiac output falls.

Do not pursue intermittent inotrope infusions as an alternative 1. Intermittent outpatient infusions have not shown improvement in symptoms or survival and are classified as potentially harmful 1.

Do not assume the patient can be "optimized" on oral medications alone 1. The requirement for inotropes every 2 weeks demonstrates that oral guideline-directed medical therapy is insufficient to maintain adequate perfusion.

Recognize that continuing inotropes in this context is palliative, not disease-modifying therapy 1. The goal is symptom control and quality of life, not survival prolongation, as inotropes increase mortality risk through arrhythmias and other mechanisms 1, 3.