Eur J Heart Fail. 2014 Apr;16(4):435-43. doi: 10.1002/ejhf.39.
Beta-blockers improve the prognosis in heart failure (HF), but their introduction may seem impossible in patients dependent on inotropic support. However, many of these patients can be titrated on beta-blockers, but there is little evidence of successful clinical strategies.
We analysed the records of inotropy-dependent patients referred for assessment for heart transplantation. Thirty-six patients (45%) could not be weaned (NW) and underwent left ventricular assist device (LVAD) implantation or transplantation, or died. However, 44 (55%) were successfully weaned (SW). Neither the aetiology (ischaemic vs. non-ischaemic) nor cardiac indexes were different in the SW as compared with the NW group (2.27±0.5 vs. 2.15±0.6 L/min/m2). The NW patients had lower LVEF (15±5% vs. 19±5%, P=0.001), higher right atrial pressure (12±6 vs. 8±6 mmHg, P=0.02), and more severe mitral regurgitation (P<0.001) than the SW patients. At discharge, 35 of 44 SW patients were receiving beta-blockers. In 29 of them, a beta-blocker could only be initiated or continued during concomitant support with i.v. enoximone for a duration of 14.1±7.2 days. Patients discharged on a beta-blocker had an LVAD/transplantation-free cumulative survival of 71% during a follow-up of 2074±201 days (confidence interval 1679–2470).
It takes time to put severely ill HF patients on beta-blockers and it may require bridging with inotropes which are independent of beta-adrenergic receptors. Whether such a strategy may result in a better clinical outcome warrants further research.
β受体阻滞剂可改善心力衰竭（HF）的预后，但在依赖正性肌力支持的患者中，其应用似乎难以实现。然而，许多此类患者可逐渐耐受β受体阻滞剂，但成功的临床策略证据有限。
我们分析了转诊行心脏移植评估的依赖正性肌力药物治疗患者的病历。36 例（45%）患者不能撤机（NW），行左心室辅助装置（LVAD）植入或移植，或死亡。然而，44 例（55%）患者成功撤机（SW）。SW 组与 NW 组的病因（缺血性与非缺血性）或心指数无差异（2.27±0.5 比 2.15±0.6 L/min/m2）。NW 患者的 LVEF 较低（15±5%比 19±5%，P=0.001），右心房压较高（12±6 比 8±6mmHg，P=0.02），且二尖瓣反流更严重（P<0.001）。出院时，44 例 SW 患者中有 35 例接受β受体阻滞剂治疗。其中 29 例仅在静脉注射依诺昔酮持续支持期间才能起始或继续应用β受体阻滞剂，时间为 14.1±7.2 天。在 2074±201 天的随访中，出院时应用β受体阻滞剂的患者 LVAD/移植无事件生存率为 71%（置信区间 1679–2470）。
使重症 HF 患者逐渐耐受β受体阻滞剂需要时间，可能需要使用不依赖β肾上腺素能受体的正性肌力药物桥接。这种策略是否可带来更好的临床结局，尚需进一步研究。
