Dobutamine acute decompensated heart failure

FIGURE 8-2. General treatment algorithm for acute decompensated heart failure (ADHF) based on clinical presentation. IV vasodilators that may be used include nitroglycerin, nesiritide, or nitroprusside. Metolazone or spironolactone may be added if the patient fails to respond to loop diuretics and a second diuretic is required. IV inotropes that may be used include dobutamine or milrinone. (D/C, discontinue HF, heart failure SBP, systolic blood pressure.) (Reprinted and adapted from J Cardiac Fail, Vol 12, pages el-el 22, copyright 2006, with permission from Elsevier.)... 

Dobutamine Betai-selective agonist t increases cAMP synthesis Increases cardiac contractility, output Acute decompensated heart failure intermittent therapy in chronic failure reduces symptoms IV only duration a few minutes Toxicity Arrhythmias. Interactions Additive with other sympathomimetics... 

Comparative studies Unlike traditional inotropic agents, levosimendan is thought to have a lower potential to cause dysrhythmias, because it does not increase intracellular calcium concentrations and myocardial oxygen consumption. Levosimendan and dobuta-mine have been compared in 50 patients with acute decompensated heart failure (NYHA class III-IV, ejection fraction <35%), mean age 68 years [20 ]. Heart rate and the number of ventricular extra beats increased significantly during infusion of levosimendan and dobutamine, but the increase in ventricular coupled beats was significant only with dobutamine. There were more episodes of non-sustained ventricular tachycardia and paroxysmal atrial fibrillation with levosimendan, but the difference was not significant. 

A much more serious complication of dobutamine therapy is ventricular dysrhythmias. Of 305 patients with acutely decompensated congestive heart failure, 58 were given dobutamine (although it is difficult to ascertain the dose), 44 were given other standard inotropic drugs such as milrinone, and 203 were treated with brain natriuretic peptide (nesiritide, 0.015 or 0.03 micrograms/kg/minute) (9). Of those given dobutamine 7% had sustained ventricular tachycardia, 17% had non-sustained ventricular tachycardia, and 5% had a cardiac arrest. In contrast. 

In the PRECEDENT study, dobutamine was compared with nesiritide (B natriuretic peptide) in patients with acutely decompensated congestive heart failure (15). The primary objective of the study was to assess the risk of ventricular dysrhythmias with the two therapies. Altogether 255 patients (mean age 61 years, 67% men) were randomized to receive dobutamine 5 micrograms/ kg/hour or one of two doses of nesiritide 0.015 or 0.03 micrograms/kg/hour. Dobutamine significantly... 

Burger AJ, Elkayam U, Neibaur MT, Haught H, Ghah J, Horton DP, Aronson D. Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated congestive heart failure receiving dobutamine versus nesiritide therapy. Am J Cardiol 2001 88(l) 35-9. 

Burger AJ, Horton DP, LeJemtel T, Ghali JK, Torre G, Dennish G, Koren M, Dinerman J, Silver M, Cheng ML, Elkayam U Prospective Randomized Evaluation of Cardiac Ectopy with Dobutamine or Natrecor Therapy. Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure the PRECEDENT study. Am Heart J 2002 144(6) 1102-8. 

Dobutamine (dobutrex, others) is indicated for the short-term treatment of cardiac decompensation post cardiac surgery or in patients with congestive heart failure or acute myocardial infarction. An infusion of dobutamine in combination with echocardiography is useful in the noninvasive assessment of patients with coronary artery disease stressing the heart with dobutamine may reveal cardiac abnormalities in selected patients. 

---