Heparin-induced thrombocytopenia/thrombosis is an immunologic reaction to unfractionated heparin characterized by thrombocytopenia, platelet activation and thrombosis. A high index of suspicion is required for timely diagnosis and treatment. Treatment is complex and outcome maybe less then satisfactory.

Background: Intravenous inotropic intervention in congestive heart failure is generally associated with a poor prognosis and is largely used as a "bridge" to mechanical support or heart transplantation. Hypothesis: We hypothesized that the inotropic support afforded by dobutamine may serve as a bridge to the introduction and intensification of angiotensin-converting enzyme (ACE) inhibitor-nitrate therapy. Methods: We studied the efficacy of transitioning inotropedependent patients in endstage heart failure from intravenous dobutamine to high-dose ACE inhibitor-nitrates, with 1-year follow-up. Forty-nine sequential dobutamine-dependent patients with left ventricularejection fraction (LVEF) 17 f 17% were treated with increasing lisinopril(l.9 f 1.5 to 46 f 28 mglday) and isosorbide dinitrate (7 f 6 to 229 f 161 mglday). Outpatient dobutamine was continued or repeat infusions pursued, as indicated, and dobutamine was tapered when feasible. Results: During the following year, 14 of 49 patients required repeat dobutamine, with home treatment with dobutamine for 6.3 f 3.7 months (n = 5). At 1 year, New York Heart Association (NYHA) classification improved from 3.6 f 0.5 to 1.9 f 1 .O, p c O.OO0 1 ; yearly hospitalizations fell from 2.7 f 2.3 to 1.2 f 3.0, p = 0.02; and LVEF rose from 17 f 7% to 24 f 1 1 %, p c O.OO0 1. At 1 year, 14 patients who remained dobutamine dependent had significantly more severe symptoms than dobutamine-independent patients (n = 35).