Dobutamine as bridge to angiotensin‐converting enzyme inhibitor‐nitrate therapy in endstage heart failure

Abstract

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).

Inotropic Drugs and Neurohormonal Antagonists in the Treatment of HF in the Elderly

“…Dobutamine has been evaluated in clinical trials [10][11][12][13][14][15][16][17][18]. Continuous use of dobutamine causes desensitization and tolerance.…”

Inotropic Therapy in Clinical Practice

“…There are no large prospective randomized trials comparing the use of dobutamine and milrinone on clinical outcomes in these patients. Both dobutamine and milrinone when used as short-term inotropic support have been shown to successfully facilitate the initiation and titration of oral vasodilator therapy [70][71][72]. Based on retrospective data, there are no significant differences between milrinone and dobutamine in terms of clinical outcomes such as incidence of arrhythmia, renal failure, heart transplant listing, or inhospital mortality rate [46].…”

Острая Сердечная Недостаточность: Рекомендациипо Диагностике И Лечению

“…Однако отношение поль зы и потенциального риска не может быть одинако вым для всех инотропных агентов. Только примене ние инотропов, стимулирующих β1 адренергические рецепторы, увеличивает цитоплазматическую мио кардиальную клеточную концентрацию кальция и сопряжено с большим риском [131,132]. Было про ведено несколько контролируемых исследований эффективности и безопасности инотропных препа ратов у больных с ОСН, и лишь в немногих оценена клиническая симптоматика и тяжесть СН, а также их отдаленный прогноз, определяемый терапией [132].…”

“…До настоя щего времени не проведено контролированных ис следований оценки эффективности и безопасности применения добутамина у пациентов с ОСН. В ряде публикаций указано на увеличение количества сер дечно сосудистых осложнений [54,131].…”