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

Background: Intravenous inotropic intervention in congestive heart failure is generally associated with a poor prognosis and is largely used as a "bri dge" to mechanical support or heart transplantation. Hypothesis: We hypothe sized that the inotropic support afforded by dobutamine may serve as a brid ge to the introduction and intensification of angiotensin-converting enzyme (ACE) inhibitor-nitrate therapy. Methods: We studied the efficacy of transitioning inotrope-dependent patien ts in endstage heart failure from intravenous dobutamine to high-dose ACE i nhibitor-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 dobut amine was continued or repeat infusions pursued, as indicated, and dobutami ne was tapered when feasible. Results: During the following year, 14 of 49 patients required repeat dobut amine, 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 h ad significantly more severe symptoms than dobutamine-independent patients (n = 35). Transplant or death occurred in 7 of 14 patients with follow-up d obutamine, 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 f ollow-up hospitalizations (3.6 +/- 5.3 vs. 0.6 +/- 0.8, p = 0.0004), and no improvement in LVEF (17 +/- 8 vs. 28 +/- 11%, p = 0.003). Conclusions: Of the patients on dobutamine inotropic support, 70% were succ essfully transitioned to ACE inhibitor-nitrate therapy, with improved sympt oms and LVEF and with reduced hospitalizations and follow-up dobutamine or transplant. Thirty percent of patients with continued need for dobutamine h ad a significantly poorer 1-year clinical outcome.