Inotropic infusions for chronic congestive heart failure: medical miracles or misguided medicinals?

There are numerous advertisements (1–7) and an occasional article (8–11) advocating intermittent infusions of milrinone or dobutamine for both inpatient and outpatient therapy of chronic heart failure. This development is of concern, because chronic administration of these same agents has been shown to increase mortality rates. One can hardly open a cardiology journal without encountering advertisements urging physicians to “open new doors” to the treatment of congestive heart failure with a drug that “helps the heart work smarter, not harderTM” (1–7). This drug, intravenous milrinone (1–7), is said to increase cardiac index while decreasing pulmonary capillary wedge pressure and systemic vascular resistance, avoid significant change in myocardial oxygen consumption or heart rate, have a rapid hemodynamic response, an easy dosing and administration schedule, a low incidence of side effects and no evidence of tachyphylaxis (1–7). Perhaps as a tribute to the effectiveness of advertising, to the obsession of hospitals with cost containment, or to the fascination that cardiologists have with hemodynamics, there is also a growing interest in establishing “heart failure clinics” that provide intermittent milrinone or dobutamine infusions therapy of chronic heart failure (8–11). Recommendations are as follows: