| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 1997;96:1165-1172.)
© 1997 American Heart Association, Inc.
Articles |
Sustained Hemodynamic Efficacy of Therapy Tailored to Reduce Filling Pressures in Survivors With Advanced Heart Failure
From the Ahmanson-UCLA Cardiomyopathy Center, UCLA School of Medicine, Los Angeles, Calif, and the Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass (L.W.S., A.S.).
Correspondence to Lynne Warner Stevenson, MD, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
Background During therapy to relieve congestion in advanced heart failure, cardiac filling pressures can frequently be reduced to near-normal levels with improved cardiac output. It is not known whether the early hemodynamic improvement and drug response can be maintained long term.
Methods and Results After referral for cardiac transplantation with initially severe hemodynamic decompensation, 25 patients survived without transplantation to undergo hemodynamic reassessment after 8±6 months of treatment tailored to early hemodynamic response. Initial changes included net diuresis, increased ACE inhibitor doses, and frequent addition of nitrates. After 8 months of therapy, early reductions were sustained for pulmonary wedge pressure (24±9 to 15±5 mm Hg early; 12±6 mm Hg late) and systemic vascular resistance (1651±369 to 1207±281 dynes·s-1·cm-5 early; 1003±193 dynes·s-1·cm-5 late). Acute response to doses persisted at reevaluation. Sustained reduction in filling pressures was accompanied by a progressive increase in stroke volume (42±10 to 56±13 mL early; 79±20 mL late), improved functional class, and freedom from resting symptoms. Study design did not control for amiodarone, which was initiated for arrhythmias in 12 patients and associated with greater improvement in cardiac index (1.8 to 3.2 L·min-1·m-2 late on amiodarone versus 2.0 to 2.6 L·min-1·m-2, P<.05).
Conclusions During chronic therapy tailored to early hemodynamic response in advanced heart failure, acute vasodilator response persists, and near-normal filling pressures can be maintained in patients who survive without transplantation. Stroke volumes at low filling pressures increase further over time. Chronic hemodynamic improvement was accompanied by symptomatic improvement, but the contributions of the monitored hemodynamic approach, increased vasodilator doses, and comprehensive outpatient management have not yet been established.
Key Words: heart failure • cardiomyopathy • diuretics • hemodynamics • vasodilation
This article has been cited by other articles:
 |
|
 |
|
  W. Mullens, Z. Abrahams, G. S. Francis, H. N. Skouri, R. C. Starling, J. B. Young, D. O. Taylor, and W.H. W. Tang Sodium nitroprusside for advanced low-output heart failure. J. Am. Coll. Cardiol., July 15, 2008; 52(3): 200 - 207. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. E. Verdejo, P. F. Castro, R. Concepcion, M. A. Ferrada, M. A. Alfaro, M. E. Alcaino, C. C. Deck, and R. C. Bourge Comparison of a Radiofrequency-Based Wireless Pressure Sensor to Swan-Ganz Catheter and Echocardiography for Ambulatory Assessment of Pulmonary Artery Pressure in Heart Failure J. Am. Coll. Cardiol., December 18, 2007; 50(25): 2375 - 2382. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. W. Stevenson, T. H. Le Jemtel, E. U. Alt, L. W. Stevenson, T. H. Le Jemtel, and E. U. Alt Hemodynamic Goals Are Relevant Circulation, February 21, 2006; 113(7): 1020 - 1033. [Full Text] [PDF]
|
|
|
|
|
|
M. Gheorghiade, F. Zannad, G. Sopko, L. Klein, I. L. Pina, M. A. Konstam, B. M. Massie, E. Roland, S. Targum, S. P. Collins, et al. Acute Heart Failure Syndromes: Current State and Framework for Future Research Circulation, December 20, 2005; 112(25): 3958 - 3968. [Full Text] [PDF]
|
|
|
|
 |
|
 The ESCAPE Investigators and ESCAPE Study Coordina Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness: The ESCAPE Trial JAMA, October 5, 2005; 294(13): 1625 - 1633. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Shah, V. Hasselblad, L. W. Stevenson, C. Binanay, C. M. O'Connor, G. Sopko, and R. M. Califf Impact of the Pulmonary Artery Catheter in Critically Ill Patients: Meta-analysis of Randomized Clinical Trials JAMA, October 5, 2005; 294(13): 1664 - 1670. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. T. Heywood, W. Elatre, R. G. Pai, S. Fabbri, and B. Huiskes Simple Clinical Criteria to Determine the Prognosis of Heart Failure Journal of Cardiovascular Pharmacology and Therapeutics, July 1, 2005; 10(3): 173 - 180. [Abstract] [PDF]
|
|
|
|
 |
|
 Endorsed by the European Society of Intensive Care, Authors/Task Force Members, M. S. Nieminen, M. Bohm, M. R. Cowie, H. Drexler, G. S. Filippatos, G. Jondeau, Y. Hasin, J. Lopez-Sendon, et al. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: The Task Force on Acute Heart Failure of the European Society of Cardiology Eur. Heart J., February 2, 2005; 26(4): 384 - 416. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Schmitt, P. Gunaruwan, N. Payne, J. Taylor, L. Lee, A. J.M. Broadley, A. K. Nightingale, J. R. Cockcroft, A. D. Struthers, J. V. Tyberg, et al. Effects of Exogenous and Endogenous Natriuretic Peptides on Forearm Vascular Function in Chronic Heart Failure Arterioscler. Thromb. Vasc. Biol., May 1, 2004; 24(5): 911 - 917. [Abstract] [Full Text]
|
|
|
|
 |
|
 R. J DiDomenico, H. Y Park, M. R. Southworth, H. M Eyrich, R. K Lewis, J. M Finley, and G. T Schumock Guidelines for Acute Decompensated Heart Failure Treatment Ann. Pharmacother., April 1, 2004; 38(4): 649 - 660. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. B. Adamson, A. Magalski, F. Braunschweig, M. Bohm, D. Reynolds, D. Steinhaus, A. Luby, C. Linde, L. Ryden, B. Cremers, et al. Ongoing right ventricular hemodynamics in heart failure: clinical value of measurements derived from an implantable monitoring system J. Am. Coll. Cardiol., February 19, 2003; 41(4): 565 - 571. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W.-S. Lee, W.-P. Huang, W.-C. Yu, K.-R. Chiou, P. Y.-A. Ding, and C.-H. Chen Estimation of preload recruitable stroke work relationship by a single-beat technique in humans Am J Physiol Heart Circ Physiol, February 1, 2003; 284(2): H744 - H750. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Weilenmann, H. Rickli, F. Follath, W. Kiowski, and H. P. Brunner-La Rocca Noninvasive Evaluation of Pulmonary Capillary Wedge Pressure by BP Response to the Valsalva Maneuver* Chest, July 1, 2002; 122(1): 140 - 145. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Nohria, E. Lewis, and L. W. Stevenson Medical Management of Advanced Heart Failure JAMA, February 6, 2002; 287(5): 628 - 640. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Erdmann The value of diuretics in chronic heart failure demonstrated by an implanted haemodynamic monitor Eur. Heart J., January 1, 2002; 23(1): 7 - 9. [Full Text] [PDF]
|
|
|
|
|
|
C.-H. Chen, B. Fetics, E. Nevo, C. E. Rochitte, K.-R. Chiou, P.-A. Ding, M. Kawaguchi, and D. A. Kass Noninvasive single-beat determination of left ventricular end-systolic elastance in humans J. Am. Coll. Cardiol., December 1, 2001; 38(7): 2028 - 2034. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. K. Nightingale, D. J. Blackman, G. R. Ellis, M. Schmitt, J. A. Morris-Thurgood, E. A. Jones, and M. P. Frenneaux Preservation of venous endothelial function in the forearm venous capacitance bed of patients with chronic heart failure despite arterial endothelial dysfunction J. Am. Coll. Cardiol., March 15, 2001; 37(4): 1062 - 1068. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Z. Popovic, M. Miric, A.N. Neskovic, J. Vasiljevic, P. Otasevic, M. Zarkovic, M. Bojic, and S. Gradinac Functional capacity late after partial left ventriculectomy: relation to ventricular geometry and performance Eur. J. Cardiothorac. Surg., January 1, 2001; 19(1): 61 - 67. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. S. Mueller, K. Chatterjee, K. B. Davis, M. A. Fifer, C. Franklin, M. A. Greenberg, A. J. Labovitz, P. K. Shah, K. J. Tuman, M. H. Weil, et al. Present use of bedside right heart catheterization in patients with cardiac disease J. Am. Coll. Cardiol., September 1, 1998; 32(3): 840 - 864. [Full Text] [PDF]
|
|
|
|
|
|
L. W. Stevenson Rites and Responsibility for Resuscitation in Heart Failure : Tread Gently on the Thin Places Circulation, August 18, 1998; 98(7): 619 - 622. [Full Text] [PDF]
|
|