A Randomized Pilot Study of Aortic Waveform Guided Therapy in Chronic Heart Failure

Abstract

BackgroundMedication 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 ResultsSubjects 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.ConclusionsMaximization 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.

Practical Suitability of a Stand-Alone Oscillometric Central Blood Pressure Monitor: A Review of the Microlife WatchBP Office Central

“…Currently, 2 randomized clinical trials have demonstrated the usefulness of treatment based on CBP measurement and augmentation index as compared to conventional therapy [60,61]. Borlaug et al [60] demonstrated among 50 patients (23 intervention and 27 control patients) with heart failure that, after 6 months, subjects who were randomized to active treatment were more likely to receive additional vasoactive therapy leading to greater improvement in peak oxygen consumption as compared with controls (1.37 ± 3.76 vs. -0.65 ± 2.21 ml min -1 kg -1 , p = 0.025), with similar reductions in aortic augmentation.…”

“…Borlaug et al [60] demonstrated among 50 patients (23 intervention and 27 control patients) with heart failure that, after 6 months, subjects who were randomized to active treatment were more likely to receive additional vasoactive therapy leading to greater improvement in peak oxygen consumption as compared with controls (1.37 ± 3.76 vs. -0.65 ± 2.21 ml min -1 kg -1 , p = 0.025), with similar reductions in aortic augmentation. Sharman et al [61] showed among 286 patients that CBP-based hypertension management resulted in significantly less medication needed to achieve BP control than usual care without adverse effects on left ventricular mass, aortic stiffness, or quality of life.…”

“…The different results of these studies are highly related to the way usual care was performed: in the study by Sharman et al [61], treatment was based on a variety of tests (office BP, 7-day home BP, 24-hour ambulatory BP, two-dimensional left ventricular mass index, symptoms, and other clinical considerations as per absolute cardiovascular risk), whereas Borlaug et al [60] relied solely on office BP measurement. In addition, there was a difference in cut-off values for CBP measurement: Sharman et al [61] used age- and sex-specific normative cSBP values derived from a large population study [62] and defined the normative range as within +1 SD from the mean normative values.…”

“…In addition, there was a difference in cut-off values for CBP measurement: Sharman et al [61] used age- and sex-specific normative cSBP values derived from a large population study [62] and defined the normative range as within +1 SD from the mean normative values. Borlaug et al [60] aimed at reducing the augmentation index to 0% with maintenance of cSBP in the range of 85-100 mm Hg.…”

Central pressure should be used in clinical practice

“…II. 27 Treatment withdrawal in this higher risk population may have been ethically questionable and all patients started the trial on maximal guidelinedirected medical therapy. The goal of active treatment was to reduce augmentation index to 0% with antihypertensive medications (provided central SBP was in an acceptable range; deemed > 85e100 mmHg), thereby 'pressure unloading' the left ventricle and enabling improved cardiac ejection and exercise tolerance.…”