Long-term vasodilator therapy for heart failure: clinical response and its relationship to hemodynamic measurements.

Abstract

SUMMARY To assess the clinical efficacy of chronic vasodilator therapy for refractory congestive heart failure, the long-term follow-up (mean 13 months, range 3-30 months) was evaluated in 56 patients treated with hydralazine, usually in combination with nitrates. In the first 6 months, 73% improved subjectively and 59% improved by one or two New York Heart Association classifications; early improvement was usually sustained. Mortality was high, 22% at 6 months and 37% at 12 months, but was significantly lower in patients who had a clinical response to vasodilators (21% in responders vs 55% in nonresponders at 1 year). The only clinical indicator that differentiated responders from nonresponders was the presence or absence of symptomatic progression before initiation of vasodilator therapy. Pulmonary artery pressure, pulmonary capillary wedge (PCW) pressure and stroke work index (SWI) before and during vasodilator therapy correlated with clinical response and survival. Fifteen of 20 patients with PCW < 20 mm Hg and SWI 30 g-m/m2 improved and survived, compared with two of 19 with PCW 20 mm Hg and SWI < 30 g-m/m2. Patients who did not have acute hemodynamic improvement generally did not improve clinically, but neither the percentage change nor the absolute change in any hemodynamic variable predicted outcome in the remaining patients.The findings of this study indicate that vasodilators produce clinical improvement in many patients with refractory heart failure and that hemodynamic measurements are helpful in predicting the outcome of therapy.

Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure.

“…In previous reports, elevated filling pressures have been variably shown to indicate a worse prognosis. [23][24][25][26][27] We also sought to examine the validity of using a peak Vo2 level of more than 14 ml/kg/min to identify patients in whom transplantation could be safely deferred. When the population was subdivided by different ranges of Vo2 (Figure 3), a peak Vo2 level of less than 10 ml/kg/min was associated with a significantly poorer survival, and a peak Vo2 of more than 14 ml/kg/min was associated with survival comparable to survival after transplantation.…”

Prognostic importance of serum sodium concentration and its modification by converting-enzyme inhibition in patients with severe chronic heart failure.

“…In general, a series of drugs was tested in each patient until a satisfactory short-term hemodynamic effect was observed at a dose that produced no adverse reactions. Drug therapy was then continued for 1 to 3 months, at which time the efficacy of the selected agent was evaluated clinically and, in the majority of the patients, by repeat right heart catheterization. If no clinical or hemodynamic benefits were observed or if adverse reactions occurred that prohibited continued treatment, alternative vasodilator agents were sought during second and third right heart catheterization procedures until a drug was found that was effective and well tolerated, until no such agent was discovered, or until death occurred.…”

Controlled trial of captopril in chronic heart failure: a rest and exercise hemodynamic study.

“…Additionally, the long-term effectiveness of several of these drugs remains controversial, perhaps because patients develop a tolerance to them. [45][46][47][48][49][50] Long-term follow-up studies have presented a less optimistic picture than the initial reports.10' 51,52 Captopril is the first oral converting-enzyme inhibitor to be studied in heart failure. The initial reports documenting its acute effectiveness gained considerable attention and provided some evidence of sustained hemodynamic and clinical improvement with maintenance captopril therapy.9' 1117 Ader et al9 documented persistent hemodynamic benefit at rest in seven patients restudied after 2 months of therapy, five of whom had an accompanying increase in treadmill exercise tolerance.…”