CLINICAL STUDY
Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure
A randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol
Marco Metra, MD*,*,
Savina Nodari, MD*,
Antonio D’Aloia, MD*,
Claudio Muneretto, MD ,
Alastair D. Robertson, PhD ,
Michael R. Bristow, MD, PhD and
Livio Dei Cas, MD*
* Cattedra di Cardiologia, Università di Brescia, Brescia, Italy
Cattedra di Cardiochirurgia, Università di Brescia; Brescia, Italy
Department of Medicine, Division of Cardiology, University of Colorado Health Sciences Center, Denver, Colorado, USA
Manuscript received December 28, 2001;
revised manuscript received May 7, 2002,
accepted June 27, 2002.
* Reprint requests and correspondence: Prof. Marco Metra, Cattedra di Cardiologia, c/o Spedali Civili, Piazza Spedali Civili, 25100 Brescia, Italy.
metramarco{at}libero.it
OBJECTIVES: We compared the hemodynamic effects of dobutamine and enoximone administration before and after long-term beta-blocker therapy with metoprolol or carvedilol in patients with chronic heart failure (HF).
BACKGROUND: Patients with HF on beta-blocker therapy may need hemodynamic support with inotropic agents, and the hemodynamic response may be influenced by both the inotropic agent and the beta-blocker used.
METHODS: The hemodynamic effects of dobutamine (5 to 20 µg/kg/min intravenously) and enoximone (0.5 to 2 mg/kg intravenously) were assessed by pulmonary artery catheterization in 29 patients with chronic HF before and after 9 to 12 months of treatment with metoprolol or carvedilol at standard target maintenance oral doses. Hemodynamic studies were performed after  12 h of wash-out from all cardiovascular medications, except the beta-blockers that were administered 3 h before the second study.
RESULTS: Compared with before beta-blocker therapy, metoprolol treatment decreased the magnitude of mean pulmonary artery pressure (PAP) and pulmonary wedge pressure (PWP) decline during dobutamine infusion and increased the cardiac index (CI) and stroke volume index (SVI) response to enoximone administration, without any effect on other hemodynamic parameters. Carvedilol treatment abolished the increase in heart rate, SVI, and CI and caused a rise, rather than a decline, in PAP, PWP, systemic vascular resistance, and pulmonary vascular resistance during dobutamine infusion. The hemodynamic response to enoximone, however, was maintained or enhanced in the presence of carvedilol.
CONCLUSIONS: In contrast with its effects on enoximone, carvedilol and, to a lesser extent, metoprolol treatment may significantly inhibit the favorable hemodynamic response to dobutamine. No such beta-blocker–related attenuation of hemodynamic effects occurs with enoximone.
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Abbreviations and Acronyms
| | ACEI | | angiotensin-converting enzyme inhibitor | | ANOVA | | analysis of variance | | CI | | cardiac index | | HF | | heart failure | | HR | | heart rate | | LVEF | | left ventricular ejection fraction | | MAP | | mean arterial pressure | | NYHA | | New York Heart Association | | PAP | | mean pulmonary artery pressure | | PDE | | phosphodiesterase | | PVR | | pulmonary vascular resistance | | PWP | | pulmonary wedge pressure | | SVI | | stroke volume index | | SVR | | systemic vascular resistance |
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