Clinical Investigation
Inotropic Agents Improve the Peripheral Microcirculation of Patients With End-Stage Chronic Heart Failure

https://doi.org/10.1016/j.cardfail.2008.02.001Get rights and content

Abstract

Background

Skeletal muscle microcirculation impairment in patients with chronic heart failure (CHF) seems to correlate with disease severity. We evaluated the microcirculation by near-infrared spectroscopy (NIRS) occlusion technique before and after inotropic infusion.

Methods

We evaluated 25 patients with stable CHF, 30 patients with end-stage CHF (ESCHF) receiving treatment with intermittent infusion of inotropic agents, and 12 healthy subjects. Thenar muscle tissue oxygen saturation (StO2%) was measured noninvasively by NIRS before, during, and after 3-minute occlusion of the brachial artery (occlusion technique) in all subjects and in patients with ESCHF before and after 6 hours of inotropic infusion (dobutamine and/or levosimendan) or placebo (N = 5).

Results

Patients with ESCHF or CHF presented significantly lower StO2% than healthy subjects (74.5% ± 7%, 78.6% ± 6%, and 85% ± 5%, respectively; P = .0001), lower oxygen consumption rate during occlusion (24.6% ± 8%/min, 28.6% ± 10%/min, and 38.1% ± 11.1%/min, respectively; P = .001), and lower reperfusion rate (327% ± 141%/min, 410% ± 106%/min, and 480% ± 133%/min, respectively; P = .002). After 6 hours of inotropic infusion, patients with ESCHF showed significantly increased StO2% (74.5% ± 7% to 82% ± 9%, P = .001), oxygen consumption rate (24.6% ± 8%/min to 29.3% ± 8%/min, P = .009), and reperfusion rate (327% ± 141%/min to 467% ± 151%/min, P = .001). No statistical difference was noted in the placebo group.

Conclusion

Peripheral muscle microcirculation as assessed by NIRS is impaired in patients with CHF. This impairment is partially reversed by infusion of inotropic agents in patients with ESCHF.

Section snippets

Patients

The study group consisted of 55 patients with CHF (48 male/7 female; mean age, 56 ± 13 years) and a group of 12 healthy subjects (8 male/4 female). Twenty-five of the patients with CHF had a diagnosis of stable, mild to moderate CHF (21 male/4 female; mean age, 54 ± 12 years), and 30 patients with CHF (27 male/3 female; mean age, 58 ± 14 years) were diagnosed with ESCHF refractory to standard optimal drug therapy, including digoxin, enalapril, spironolactone, furosemide, and oral amiodarone.

Results

Patients with ESCHF and CHF presented significantly lower StO2 than healthy subjects (74.5% ± 7%, 78.6% ± 6%, and 85% ± 5%, respectively; P = .0001) and lower oxygen consumption rate during the occlusion of the brachial artery (24.6% ± 8%/min, 28.6% ± 10%/min, and 38.1% ± 11.1%/min, respectively; P = .001) (Figure 1; Table 2). The reperfusion rate differed significantly among patients with ESCHF, patients with CHF, and healthy subjects (327% ± 141%/min, 410% ± 106%/min, and 480% ± 133%/min,

Discussion

This study shows that patients with CHF are characterized by marked abnormalities in skeletal muscle tissue microcirculation as assessed by the NIRS occlusion technique, which can be partly reversed by infusion of inotropic agents.

Specifically, resting skeletal muscle tissue oxygenation was lower in patients with CHF, and this reduction was more prominent in patients with ESCHF than in healthy subjects. In addition, the brachial artery occlusion led to a slower oxygen consumption rate and

Limitations

A limitation of our study was the relatively small number of patients with ESCHF who participated. Patients with ESCHF included in the study were receiving 3 different inotropic regimens (dobutamine and/or levosimendan), making comparison of the 3 groups difficult because of the small number of patients. However, all patients showed improved tissue oxygenation after infusion of inotropic agents.

Conclusions

Our study has shown that peripheral muscle microcirculation, as assessed with the NIRS occlusion technique, is impaired in patients with CHF and that the degree of microcirculatory dysfunction is associated with disease severity. This impairment seems to be partly reversed with infusion of inotropic agents. The NIRS occlusion technique might be a useful clinical tool in the evaluation of the peripheral microcirculation in patients with CHF. Further studies are needed to evaluate the long-term

References (46)

  • A.S. Dean et al.

    Impaired vasoreactivity in end-stage heart failure patients on intravenous inotropic support

    J Card Fail

    (2005)
  • J.N. Nanas et al.

    Efficacy and safety of intermittent, long-term, concomitant dobutamine and levosimendan infusions in severe heart failure refractory to dobutamine alone

    Am J Cardiol

    (2005)
  • J.N. Nanas et al.

    Hemodynamic effects of levosimendan added to dobutamine in patients with decompensated advanced heart failure refractory to dobutamine alone

    Am J Cardiol

    (2004)
  • J.A. Wahr et al.

    Near-infrared spectroscopy: theory and applications

    J Cardiothorac Vasc Anesth

    (1996)
  • A. Siafaka et al.

    Acute effects of smoking on skeletal muscle microcirculation monitored by near-infrared spectroscopy

    Chest

    (2007)
  • C.J. Hogan et al.

    The utility of microvascular perfusion assessment in heart failure: a pilot study

    J Card Fail

    (2005)
  • S. Matsui et al.

    Assessment of working skeletal muscle oxygenation in patients with chronic heart failure

    Am Heart J

    (1995)
  • R. Belardinelli et al.

    Skeletal muscle oxygenation and oxygen uptake kinetics following constant work rate exercise in chronic congestive heart failure

    Am J Cardiol

    (1997)
  • D. Freimark et al.

    Impact of short-term intermittent intravenous dobutamine therapy on endothelial function in patients with severe chronic heart failure

    Am Heart J

    (2004)
  • D.M. Mancini et al.

    Effect of dobutamine on skeletal muscle metabolism in patients with congestive heart failure

    Am J Cardiol

    (1990)
  • M.S. Nieminen et al.

    Hemodynamic and neurohumoral effects of continuous infusion of levosimendan in patients with congestive heart failure

    J Am Coll Cardiol

    (2000)
  • J.T. Parissis et al.

    Effects of levosimendan on circulating pro-inflammatory cytokines and soluble apoptosis mediators in patients with decompensated advanced heart failure

    Am J Cardiol

    (2004)
  • R. Zelis et al.

    A comparison of the effects of vasodilator stimuli on peripheral resistance vessels in normal subjects and in patients with congestive heart failure

    J Clin Invest

    (1968)
  • Cited by (0)

    This study was partly funded by grant from the Special Account for Research Grants of the National and Kapodistrian University of Athens, Greece, and by the Thorax Foundation.

    View full text