March 21, 2014Open Access
View Full PaperA Randomized Pilot Study of Aortic Waveform Guided Therapy in Chronic Heart Failure
Key Result
Aortic pressure-guided treatment improved peak oxygen consumption compared with conventional therapy in chronic heart failure patients (1.37 vs -0.65 mL/min/kg, P=0.025).
Study Design
Type
RCT (n=50)
Randomization
randomized
Structured PICO
Does aortic pressure-guided treatment improve exercise capacity and cardiovascular structure-function in patients with chronic heart failure?
P
Population
50 subjects with chronic heart failure
I
Intervention
Aortic pressure-guided treatment (sequential addition of vasoactive therapies beyond goal-directed medical therapy with the goal to reduce aortic augmentation index to 0%) over 6 monthly visits
C
Comparator
Conventional therapy (sequential addition of vasoactive therapies beyond goal-directed medical therapy if brachial pressure remained elevated)
O
Outcome
Peak oxygen consumption (exercise capacity)surrogate
Titrating vasoactive medications based on central aortic pressure rather than brachial pressure improves exercise capacity in patients with chronic heart failure.
Main Result
Absolute Event Rate: 1.37% vs -0.65%
p-value: p=0.025
Abstract
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.