Intermittent Outpatient Infusions of Inotrope Promising For Advanced CHF

	August 23, 1999 - Results of 2 small studies published in the
August issue of the American Heart Journal suggest that intermittent
outpatient infusions of an IV inotropic drug may benefit patients with
advanced CHF, although many questions remain.
	In the first paper, Dr. Anthony Hatzizacharias reports that
intermittent milrinone infusion "leads to a prompt, reliable improvement
in the overall hemodynamic situation, that is sustained during repeated
long-term administrations and 4 months after therapy."
	In 36 end-stage CHF patients, IV milrinone significantly
decreased pulmonary arterial pressure, pulmonary capillary wedge pressure
and systemic and pulmonary resistance. It also increased cardiac index.
The IV doses were given continuously for 72 hours, 20 days apart, for a
total of 4 cycles. Patients were eligible only if they responded to
milrinone during a 72-hour baseline study in a hospital.
	"These first results of a small study raise the possibility
that, given properly, milrinone may have an important role in end-stage
CHF," Dr. Hatzizacharias said.

	Elsewhere in the same issue of the journal, Italian cardiologists
led by Dr. Fabrizio Oliva present data from the DICE trial. In 38 patients
with severe CHF who tolerated 48 hours of dobutamine infusion in a
hospital-based initial study, low-dose IV dobutamine was given on an
outpatient basis for 48 to 72 hours per week for 6 months.
	The authors say that while dobutamine was well tolerated, "it
did not improve functional status and did not significantly increase
mortality." However, "hospitalizations for all causes and for worsening
of CHF tended to be fewer in the dobutamine group," they note.
	The DICE group concludes that intermittent infusion of dobutamine
may be an alternative for "carefully selected patients with severely
symptomatic and advanced heart failure when conventional therapies have
failed."

	In an accompanying editorial, Dr. Marc Silver of Christ Hospital
and Medical Center in Oak Lawn, Illinois, says that a principal problem
in evaluating outpatient infusion of inotropic agents in CHF is the
uncertainty about how to define success. "Is it measured by hemodynamics
or symptoms, mortality rates, or life quality?" "Have we learned better
from the new findings whether this therapy does good or harm, helps or
hinders, promotes life quality or quantity? Probably not," Dr. Silver
writes. "I would argue that it is our own internal uncertainty about what
the goals are for these patients that has led us to this point in time."

Am Heart J 1999;191-192,241-253