A randomized pilot study of aortic waveform guided therapy in chronic heart failure.
BACKGROUND
Medication treatment decisions in heart failure (HF) are currently informed by measurements of brachial artery pressure, but ventricular afterload is more accurately represented by central aortic pressure, which differs from brachial pressure. We sought to determine whether aggressive titration of vasoactive medicines beyond goal-directed heart failure medical therapy (GDMT) based upon aortic pressure improves exercise capacity and cardiovascular structure-function.


METHODS AND RESULTS
Subjects with chronic HF (n=50) underwent cardiopulmonary exercise testing, echocardiography, and arterial tonometry to measure aortic pressure and augmentation index, and were then randomized to aortic pressure-guided treatment (active, n=23) or conventional therapy (control, n=27). Subjects returned for 6 monthly visits wherein GDMT was first optimized. Additional vasoactive therapies were then sequentially added with the goal to reduce aortic augmentation index to 0% (active) or if brachial pressure remained elevated (control). Subjects randomized to active treatment experienced greater improvement in peak oxygen consumption compared with controls (1.37±3.76 versus -0.65±2.21 mL min(-1) kg(-1), P=0.025) though reductions in aortic augmentation index were similar (-7±9% versus -5±6%, P=0.46). Forward stroke volume increased while arterial elastance and left ventricular volumes decreased in all participants, with no between-group difference. Subjects randomized to active treatment were more likely to receive additional vasoactive therapies including nitrates, aldosterone antagonists and hydralazine, with no increased risk of hypotension or worsening renal function.


CONCLUSIONS
Maximization of goal-directed medical therapy in heart failure patients may enhance afterload reduction and lead to reverse remodeling, while additional medicine titration based upon aortic pressure data improves exercise capacity in patients with heart failure.
['Borlaug|Barry A|BA|', 'Olson|Thomas P|TP|', 'Abdelmoneim|Sahar S|SS|', 'Abdelmoneim Mohamed|Sahar|S|', 'Melenovsky|Vojtech|V|', 'Sorrell|Vincent L|VL|', 'Noonan|Kelly|K|', 'Lin|Grace|G|', 'Redfield|Margaret M|MM|']
D000368:Aged D000369:Aged, 80 and over D000959:Antihypertensive Agents D001011:Aorta D001130:Arizona D062186:Arterial Pressure D002908:Chronic Disease D004359:Drug Therapy, Combination D015150:Echocardiography, Doppler D005080:Exercise Test D017079:Exercise Tolerance D005260:Female D006333:Heart Failure D006801:Humans D008297:Male D008365:Manometry D008875:Middle Aged D008910:Minnesota D010865:Pilot Projects D011237:Predictive Value of Tests D016037:Single-Blind Method D013997:Time Factors D016896:Treatment Outcome D014665:Vasodilator Agents D016277:Ventricular Function, Left D020257:Ventricular Remodeling
heart failure exercise aortic pressure waveform vasodilator ventricular function