Hemodynamic effects of Ivabradine in addition to dobutamine in patients with severe systolic dysfunction

作者：Gallet Romain^*; Ternacle Julien; Damy Thibaud; Guendouz Soulef; Bremont Camille; Seemann Aurelien; Gueret Pascal; Dubois Rande Jean Luc; Lim Pascal

来源：International Journal of Cardiology, 2014, 176(2): 450-455.

DOI：10.1016/j.ijcard.2014.07.093

• Heart failure
• Dobutamine
• Ivabradine
• Oxygen consumption
• Cardiogenic shock

Background: Dobutamine induced tachycardia increases myocardial oxygen consumption and impairs ventricular filling. We hypothesized that Ivabradine may be efficient to control dobutamine induced tachycardia.
Methods: We assessed the effects of Ivabradine in addition to dobutamine in stable heart failure (HF) patients (LVEF < 35%, n = 22, test population) and validated its effects in refractory cardiogenic shock patients (n = 9, validation population) with contraindication to cardiac assistance or transplant. In the test population (62 +/- 17 years, LVEF = 24 +/- 8%), systolic and diastolic function were assessed at rest and under dobutamine [10 gamma/min], before and after Ivabradine [5 mg per os]. In the validation population (54 +/- 11 years, LVEF = 22 +/- 7%), Ivabradine [5 mg twice a day] was added to the dobutamine infusion.
Results: In the test population, Ivabradine decreased heart rate [HR] at rest and during dobutamine echocardiography (-9 +/- 8 bpm, P = 0.0004). The decrease in HR was associated with a decrease in cardiac power output and an increase in diastolic duration at rest (+ 74 +/- 67 ms, P = 0.0002), and during dobutamine infusion (+ 75 +/- 67 ms, P < 0.0001). Change in LVEF during dobutamine was greater after Ivabradine treatment than before (+ 7.2 +/- 4.7% vs. + 3.6 +/- 4.2%, P = 0.002). In the validation population, Ivabradine decreased HR (-18 +/- 11 bpm, P = 0.008) and improved diastolic filling time (+ 67 +/- 42 ms, P = 0.012) without decreasing cardiac output. At 24 h, Ivabradine improved systolic blood pressure (+ 9 +/- 5 mm Hg, P = 0.007), daily urine output (+ 0.7 +/- 0.5 L, P = 0.008), oxygen balance (Delta Scv02 = + 13 +/- 15%, P = 0.010), and NT-pro BNP (-2270 +/- 1912 pg/mL, P = 0.017). Finally, only 2/9 (22%) patients died whereas expected mortality determined from a historical cohort was 78% (P = 0.017).
Conclusion: This pilot study demonstrates the safety and potential benefit of a HR lowering agent in cardiogenic shock.

• 出版日期2014-9-20