Journal of Cardiac Failure Vol. 2 No. 4 1996 Clinical Investigations Hemodynamic Predictors of Early Intolerance and Long-term Effects of Propranolol in Dilated Cardiomyopathy K. K. TALWAR, DM, B. BHARGAVA, DM, R T. UPASANI, DM, S. VERMA, DM, T. KAMLAKAR, DM, R CHOPRA, MD New Delhi, India ABSTRACT Background: Fifty-six patients with dilated cardiomyopathy (DCM) (aged 14-68 years) and background therapy of angiotensin-converting enzyme inhibitors, diuretics, and digoxin were given an initial challenge of propranolol in gradually increasing doses. These patients were studied noninvasivelyand hemodynamically and subjected to right ventricle biopsy. Methods and Results: Forty-four patients tolerated propranolol and received the drug for 6 months; 12 patients deteriorated after starting the drug with worsening of congestive heart failure and/or hypotension. The patients who did not tolerate propranolol had higher left ven- tricular end-diastolic dimension (73 _+8 vs 66 + 8 ram, P < .05), and severe mitral regurgita- tion was more common. Hemodynamically these patients had higher heart rate, right ventricu- lar end-diastolic pressure, mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and left ventricular end-diastolic pressure (102 + 16 vs 89 + 12 beats/rain, 15 + 7 vs 9 -+ 4, 39 + 16 vs 31 _+ 12, 28 + 8 vs 21 + 8, 28 + 8 vs 22 + 8 mmHg, respectively, P < .01). These patients had a significantly lower cardiac index (1.9 + 0.6 vs 2.5 + 0.6 L/min/m 2, P < .01). Forty patients completed 6 months follow-up evaluation and were further subjected to repeat noninvasive and hemodynamic study. There was a significant improvement in New York Heart Association class, cardiothoracic ratio, and left ventricular end-diastolic dimension (68% vs 62%, 66 + 8 vs 62 + 7 ram, respectively, P < .01), while the ejection fraction (EF) rose from 23 to 35% (P < .001). Hemodynamically, there was a significant decrease in heart rate, right ventricular end-diastolic pressure, mean pulmonary artery pressure, mean pul- monary artery wedge pressure, and left ventricular end-diastolic pressure (91 + 14 vs 71 + 5 beats/nfin, 9 + 4 v s 5 _ + 3 , 3 2 + 11vs22+7,25+9vs 17+8,21+7vs 14+4mmHg, P < .05). The cardiac index rose from 2.3 + 0.6 to 3.2 + 0.7 L/min/m 2 (P < .01). Conclusions: Propranolol in dilated cardiomyopathy is associated with significant intoler- ance. Those who tolerate propranolol seem to have long-term beneficial effects. This study is limited as it is uncontrolled and nonrandomized. Key Words: beta-blocker, heart failure. From the Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India. Manuscript received Feb. 5, 1996; revised manuscriptreceived July 11, 1996; revisedmanuscriptacceptedAugust 21, 1996. Reprintrequests: K. K. Talwar,DM, Departmentof Cardiology, Car- diothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi 110029, India. Numerous beta-adrenergic blocking agents have been evaluated in patients with dilated cardiomyopathy (DCM) (1-16). This followed the pioneering efforts of Waagstein and associates in 1975 who reported its beneficial effects in DCM. The same group demonstrated clinical deterio- ration on withdrawal of metoprolol reversible with rein- 273