SUSTAINED HEMODYNAMIC EFFICACY OF THERAPY TAILORED TO REDUCE FILLING PRESSURES IN SURVIVORS WITH ADVANCED HEART-FAILURE

Background During therapy to relieve congestion in advanced heart fail ure, cardiac filling pressures can frequently be reduced to near-norma l levels with improved cardiac output. It is not known whether the ear ly hemodynamic improvement and drug response can be maintained long te rm. Methods and Results After referral for cardiac transplantation wit h initially severe hemodynamic decompensation, 25 patients survived wi thout 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 freq uent 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. S ustained reduction in filling pressures was accompanied by a progressi ve increase in stroke volume (42 +/- 10 to 56 +/- 13 mL early; 79 +/- 20 mt late), improved functional class, and freedom from resting sympt oms. 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 versu s 2.0 to 2.6 L.min(-1).m(-2), P < .05). Conclusions During chronic the rapy tailored to early hemodynamic response in advanced heart failure, acute vasodilator response persists, and near-normal filling pressure s can be maintained in patients who survive without transplantation. S troke volumes at low filling pressures increase further over time. Chr onic hemodynamic improvement was accompanied by symptomatic improvemen t, but the contributions of the monitored hemodynamic approach, increa sed vasodilator doses, and comprehensive outpatient management have no t yet been established.