title: A hemodynamically oriented echocardiography-based strategy in the treatment of congestive heart failure.
abstract: BACKGROUND
  The therapeutic applicability of echocardiographic evaluations remains poorly defined in heart failure (HF). We hypothesized that an individualized echocardiography-guided strategy would be feasible and significantly reduce morbidity compared with the conventional clinically oriented treatment.
  
  
  RESULTS
  We conducted a single-center clinical trial comparing an echocardiography-guided strategy aimed at achieving a near-normal hemodynamic profile and a conventional clinically oriented strategy for HF management. The echocardiography-guided strategy was based on sequential echocardiograms to evaluate hemodynamically derived parameters. Pharmacologic therapy was guided according to a predefined protocol. The primary efficacy end point was time to the first event of combined all-cause mortality and all-cause hospitalization or emergency department visit up to 1 year of follow-up. We studied 96 outpatients with HF, enrolled from 1999 to 2003, with predominantly nonischemic cause and a mean left ventricular ejection fraction of 26% +/- 6%. Event-free survival at a mean follow-up of 230 days was 58.5% with the echocardiography-guided strategy and 36.5% with the clinically based strategy (relative risk = 0.54, 95% confidence interval = 0.31-0.97, P = .04). More patients in the echocardiography-based group received high-dose loop diuretics (absolute difference of 19%, P = .02) and hydralazine (absolute difference of 30%, P < .001). Significant reductions of estimates of pulmonary artery systolic pressure (mean difference of -9 mm Hg, P = .02) and systemic vascular resistance index (mean difference of -700 dyn x sec x m2 x cm5, P = .02) were observed in the echocardiography-guided group.
  
  
  CONCLUSIONS
  A hemodynamically oriented echocardiography-based strategy is feasible and decreases HF morbidity. This benefit could be attributed in part to the rational and individualized use of higher doses of diuretics and vasodilators.
authors.affiliation: Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil.
authors.forename: Luis E
authors.initials: LE
authors.lastname: Rohde
authors.forename: Dora V
authors.initials: DV
authors.lastname: Palombini
authors.forename: Carisi A
authors.initials: CA
authors.lastname: Polanczyk
authors.forename: Lívia A
authors.initials: LA
authors.lastname: Goldraich
authors.forename: Nadine
authors.initials: N
authors.lastname: Clausell
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D004452:Echocardiography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016037:Single-Blind Method; D016896:Treatment Outcome