Early and medium term results of tailored therapy for heart failure

Patients (pts) with advanced chronic heart failure, in NYHA functional class IV, refractory to conventional medical therapy, show a poor short-term survival prognosis. Heart transplant remains the therapy of choice but it can currently be performed in only a minority of pts. Therapy tailored to hemodynamic goals has been suggested as a potential alternative for patients with advanced congestive heart failure. Intravenous and, subsequently, oral vasodilators (v) and diuretics (d) are titrated, in order to achieve specific hemodynamic parameters: systolic arterial pressure (SAP) > 80 mmHg, pulmonary wedge pressure (PWP) < 15 mmHg, right atrial pressure (RAP) < 8 mmHg, and systemic vascular resistance (SVR) < 1200 dynes.sec.cm-5.

To assess short and medium term (two years) results of a tailored therapy management program for treatment of patients with advanced heart failure.

27 pts (19 males, 61 +/- 10 years), NYHA functional class IV, with dilated cardiomyopathy (13 idiopathic, 10 ischemic, 4 hypertensive), 17 with exclusion criteria for heart transplantation, were included. Echocardiographic left ventricular end-diastolic dimension and ejection fraction were 68 +/- 8 mm and 20 +/- 9%, respectively. Initial (i) serum sodium (Na+) was 136 +/- 5 mEq/l and i serum creatinine (Cr) was 1.4 +/- 0.8 mg/dl. Baseline, at referral, hemodynamics: SAP = 125 +/- 23, PWP = 23 +/- 6, RAP = 12 +/- 6, cardiac index (CI) = 1.9 +/- 0.5 l/min/m2, SVR = 2193 +/- 670. Using bedside right heart catheterization (Swan-Ganz catheter) we set out to achieve the above hemodynamic goals.

1) v and d used: sodium nitroprusside--cumulative dose = 196 +/- 121 mg, captopril--daily dose (dd) = 157 +/- 95 mg, isosorbide dinitrate--dd = 91 +/- 57 mg, hydralazine--dd = 95 +/- 67 mg, and furosemide--dd = 105 +/- 70 mg; 2) final (f) hemodynamic parameters on tailored therapy: SAP = 109 +/- 20*, PWP = 12 +/- 3*, RAP = 4 +/- 3*, CI = 2.5 +/- 0.6*, SVR = 1317 +/- 340* (*: p < 0.001 vs baseline); 3) duration of invasive monitoring was 3.0 +/- 1.9 days; 4) f Na+ = 134 +/- 5, and f Cr = 1.5 +/- 0.8 (NS vs i); 5) there was one (4%) in-hospital death; functional class of discharged pts: III--4 pts, II--18 pts, I--4 pts; 6) nine pts (35%) died after discharge--three due to refractory heart failure and six (including two potential heart transplant candidates) had sudden death; 7) actuarial survival (Kaplan-Meyer method): at 6 months (m)--80%, 12 m--71%, 18 m--64%, 24 m--55%; 8) after a mean follow-up of 18 +/- 8 m, functional class in survivors was: NYHA IV--2 pts, III--4 pts, II--8 pts, and I--3 pts.

Therapy tailored to hemodynamic goals is a valid approach for pts with advanced heart failure, showing good hemodynamic and functional short-term results, and reasonable survival at two years. The significant incidence of sudden death demands strategies for risk stratification and a search for prophylactic measures in this population.