A Hemodynamically Oriented Echocardiography-Based Strategy in the Treatment of Congestive Heart Failure

• Published in: Journal of cardiac failure 2007-10, Vol.13 (8), p.618-625
• Main Authors: Rohde, Luis E., MD, ScD, Palombini, Dora V., MD, ScD, Polanczyk, Carisi A., MD, ScD, Goldraich, Lívia A., MD, Clausell, Nadine, MD, PhD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Blood Pressure - physiology; Cardiovascular; echocardiography; Echocardiography - methods; Female; Follow-Up Studies; Heart failure; Heart Failure - diagnostic imaging; Heart Failure - physiopathology; Heart Failure - therapy; Heart Rate - physiology; hemodynamic; Humans; Male; Middle Aged; Single-Blind Method; Treatment Outcome
• ISSN: 1071-9164; 1532-8414
• DOI: 10.1016/j.cardfail.2007.05.003

Abstract Background The therapeutic applicability of echocardiographic evaluations remains poorly defined in heart failure (HF). We hypothesized that an individualized echocardiography-guided strategy would be feasible and significantly reduce morbidity compared with the conventional clinically oriented treatment. Methods and Results We conducted a single-center clinical trial comparing an echocardiography-guided strategy aimed at achieving a near-normal hemodynamic profile and a conventional clinically oriented strategy for HF management. The echocardiography-guided strategy was based on sequential echocardiograms to evaluate hemodynamically derived parameters. Pharmacologic therapy was guided according to a predefined protocol. The primary efficacy end point was time to the first event of combined all-cause mortality and all-cause hospitalization or emergency department visit up to 1 year of follow-up. We studied 96 outpatients with HF, enrolled from 1999 to 2003, with predominantly nonischemic cause and a mean left ventricular ejection fraction of 26% ± 6%. Event-free survival at a mean follow-up of 230 days was 58.5% with the echocardiography-guided strategy and 36.5% with the clinically based strategy (relative risk = 0.54, 95% confidence interval = 0.31–0.97, P = .04). More patients in the echocardiography-based group received high-dose loop diuretics (absolute difference of 19%, P = .02) and hydralazine (absolute difference of 30%, P < .001). Significant reductions of estimates of pulmonary artery systolic pressure (mean difference of −9 mm Hg, P = .02) and systemic vascular resistance index (mean difference of −700 dyn.sec.m2 .cm5 , P = .02) were observed in the echocardiography-guided group. Conclusion A hemodynamically oriented echocardiography-based strategy is feasible and decreases HF morbidity. This benefit could be attributed in part to the rational and individualized use of higher doses of diuretics and vasodilators.