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

- Ivabradine in addition to dobutamine may control dobutamine induced tachycardia.
- Ivabradine was added to dobutamine in stable HF and cardiogenic shock patients.
- Ivabradine is safe and efficient to control heart rate during dobutamine infusion.
- The decrease in heart rate is associated with improvement of left ventricle filling.
- In cardiogenic shock, hemodynamic improvement is observed after Ivabradine addition.

BackgroundDobutamine induced tachycardia increases myocardial oxygen consumption and impairs ventricular filling. We hypothesized that Ivabradine may be efficient to control dobutamine induced tachycardia.MethodsWe 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 [10γ/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.ResultsIn 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 (ΔScv02 = + 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).ConclusionThis pilot study demonstrates the safety and potential benefit of a HR lowering agent in cardiogenic shock.