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Dobutamine as bridge to angiotensin-converting enzyme inhibitor-nitrate therapy in endstage heart failure
T B Levine1, A B Levine, W G Elliott
1Michigan Institute for Heart Failure and Transplant Care, Botsford General Hospital, Farmington Hills 48336, USA.
Insights
Transitioning congestive heart failure patients from dobutamine to ACE inhibitor-nitrate therapy improved outcomes for 70%, reducing hospitalizations and improving heart function. Those requiring continued dobutamine had poorer prognoses.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Intravenous inotropic agents in heart failure often indicate a poor prognosis, serving as a temporary measure before advanced treatments.
- Dobutamine is frequently used for short-term inotropic support in end-stage heart failure.
Purpose of the Study:
- To evaluate the efficacy of transitioning dobutamine-dependent patients with end-stage heart failure to high-dose angiotensin-converting enzyme (ACE) inhibitor-nitrate therapy.
- To assess the feasibility of using ACE inhibitor-nitrate therapy as a bridge to wean patients off dobutamine support.
Main Methods:
- A cohort of 49 dobutamine-dependent heart failure patients with low ejection fraction (LVEF 17±17%) were treated with escalating doses of lisinopril and isosorbide dinitrate.
- Outpatient dobutamine infusions were continued as needed, with efforts to taper support. Patients were followed for 1 year.
Main Results:
- 70% of patients (35/49) were successfully transitioned off dobutamine, showing significant improvements in New York Heart Association (NYHA) class (3.6 to 1.9), reduced hospitalizations (2.7 to 1.2), and increased LVEF (17% to 24%).
- 14 patients required continued or repeat dobutamine infusions, experiencing significantly worse outcomes, including higher mortality or need for transplant (p=0.03).
- Patients with poor outcomes (death/transplant) had persistently higher NYHA class and lower LVEF compared to those free of dobutamine.
Conclusions:
- High-dose ACE inhibitor-nitrate therapy is effective in transitioning a majority of dobutamine-dependent heart failure patients to long-term oral medication.
- Successful transition is associated with improved clinical status, reduced hospitalizations, and better LVEF.
- Continued reliance on dobutamine indicates a poorer prognosis and highlights the need for advanced therapies.
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 inotrope-dependent 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 ventricular ejection fraction (LVEF) 17+/-17% were treated with increasing lisinopril (1.9+/-1.5 to 46+/-28 mg/day) and isosorbide dinitrate (7+/-6 to 229+/-161 mg/day). 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+/-3.7 months (n = 5). At 1 year, New York Heart Association (NYHA) classification improved from 3.6+/-0.5 to 1.9+/-1.0, p < 0.0001; yearly hospitalizations fell from 2.7+/-2.3 to 1.2+/-3.0, p = 0.02; and LVEF rose from 17+/-7% to 24+/-11%, p < 0.0001. At 1 year, 14 patients who remained dobutamine dependent had significantly more severe symptoms than dobutamine-independent patients (n = 35). Transplant or death occurred in 7 of 14 patients with follow-up dobutamine, and in 5 of 35 patients free of subsequent dobutamine, p = 0.03. Patients with poor outcome (transplant n = 10, death n = 12) continued to be more limited (NYHA 2.7+/-0.9 vs. 1.7+/-0.9, p = 0.0002), with more follow-up hospitalizations (3.6+/-5.4 vs. 0.6+/-0.8, p = 0.0004), and no improvement in LVEF (17+/-8vs. 28+/-11%, p = 0.003).
Conclusions:
Of the patients on dobutamine inotropic support, 70% were successfully transitioned to ACE inhibitor-nitrate therapy, with improved symptoms and LVEF, and with reduced hospitalizations and follow-up dobutamine or transplant. Thirty percent of patients with continued need for dobutamine had a significantly poorer 1-year clinical outcome.
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