多巴酚丁胺作为晚期心力衰竭患者过渡到血管紧张素转换酶抑制剂-硝酸盐治疗的桥梁。

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

作者信息

Levine T B, Levine A B, Elliott W G, Narins B, Stomel R J

机构信息

Michigan Institute for Heart Failure and Transplant Care, Botsford General Hospital, Farmington Hills 48336, USA.

出版信息

Clin Cardiol. 2001 Mar;24(3):231-6. doi: 10.1002/clc.4960240311.

DOI:10.1002/clc.4960240311

PMID:11288970

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6654832/

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 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.

摘要

背景

充血性心力衰竭的静脉正性肌力药物干预通常与不良预后相关，主要用作机械支持或心脏移植的“桥梁”。

假设

我们假设多巴酚丁胺提供的正性肌力支持可作为引入和强化血管紧张素转换酶（ACE）抑制剂 - 硝酸盐治疗的桥梁。

方法

我们研究了晚期心力衰竭中依赖正性肌力药物的患者从静脉多巴酚丁胺转换为高剂量ACE抑制剂 - 硝酸盐的疗效，并进行了1年的随访。49例连续依赖多巴酚丁胺且左心室射血分数（LVEF）为17±17%的患者接受了递增剂量的赖诺普利（从1.9±1.5毫克/天增加到46±28毫克/天）和异山梨醇二硝酸酯（从7±6毫克/天增加到229±161毫克/天）治疗。根据需要继续门诊多巴酚丁胺治疗或进行重复输注，可行时逐渐减少多巴酚丁胺剂量。

结果

在接下来的一年中，49例患者中有14例需要重复使用多巴酚丁胺，在家中使用多巴酚丁胺治疗6.3±3.7个月（n = 5）。1年后，纽约心脏协会（NYHA）分级从3.6±0.5改善至1.9±1.0，p < 0.0001；年度住院次数从2.7±2.3降至1.2±3.0，p = 0.02；LVEF从17±7%升至24±11%，p < 0.0001。1年后，14例仍依赖多巴酚丁胺的患者症状明显比不依赖多巴酚丁胺的患者（n = 35）严重。接受随访多巴酚丁胺治疗的14例患者中有7例进行了移植或死亡，在随后未使用多巴酚丁胺的35例患者中有5例，p = 0.03。预后不良的患者（移植n = 10，死亡n = 12）仍然受限更明显（NYHA 2.7±0.9 vs. 1.7±0.9，p = 0.0002），随访住院次数更多（3.6±5.4 vs. 0.6±0.8，p = 0.0004），LVEF无改善（17±8 vs. 28±11%，p = 0.003）。