Aortic Waveform Analysis to Individualize Treatment in Heart Failure.
BACKGROUND
Afterload reduction is a cornerstone in the management of patients with heart failure (HF) and reduced ejection fraction. However, arterial load and the effect of HF therapies on afterload might vary between individuals. Tailoring vasoactive medicines to patients with HF based upon better understanding of arterial afterload may enable better individualization of therapy.


RESULTS
Subjects with HF and reduced ejection fraction underwent aggressive titration of vasoactive HF therapies with assessment of central aortic waveforms analyzed using pulse wave, wave separation, and arterial reservoir models. Clinical response to treatment was assessed using the 6-minute walk test distance, which increased in 25 subjects and decreased or remained unchanged in 13. Subjects with improvement on therapy displayed higher aortic pressure wave pulsatility (central pulse pressure [PP], reflected pressure wave, and reservoir pressure) at study entry compared with subjects without improvement (all P<0.05). Parameters derived by the arterial analysis methods were strongly correlated with one another and displayed similar ability to predict improvement. Aortic pressure pulsatility significantly decreased in subjects with functional improvement, whereas no change was observed in patients without functional improvement (P for interaction <0.05). These differences in arterial load at baseline and on therapy were not apparent from conventional brachial artery cuff pressure assessments.


CONCLUSIONS
Increased aortic pressure wave pulsatility and greater decrease in pulsatility on treatment are associated with functional improvement in patients with HF and reduced ejection fraction receiving aggressive vasodilator titration. These differences are not identifiable using brachial cuff pressures. Central aortic waveform analysis may enable better individualization of vasoactive therapies in chronic HF and reduced ejection fraction.


BACKGROUND
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00588692.
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Peter
P
Wohlfahrt
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Vojtech
V
Melenovsky
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Margaret M
MM
Redfield
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Thomas P
TP
Olson
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Grace
G
Lin
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Sahar S
SS
Abdelmoneim
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Bernhard
B
Hametner
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.).
Siegfried
S
Wassertheurer
From the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (P.W., V.M., M.M.R., T.P.O., G.L., S.S.A., B.A.B.); International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic (P.W.); Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic (P.W.); Departments of Preventive Cardiology (P.W.) and Cardiology (V.M.), Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic; and Health and Environment Department, AIT Austrian Institute of Technology, Vienna, Austria (B.H., S.W.). borlaug.barry@mayo.edu.
Barry A
BA
Borlaug
D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000187:drug effects* / Q000503:physiopathology; D062186:Arterial Pressure / Q000187:drug effects*; D002908:Chronic Disease; D005080:Exercise Test; D017079:Exercise Tolerance / Q000187:drug effects; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D010865:Pilot Projects; D011673:Pulsatile Flow / Q000187:drug effects*; D063177:Pulse Wave Analysis; D020127:Recovery of Function; D016037:Single-Blind Method; D013318:Stroke Volume / Q000187:drug effects; D013997:Time Factors; D016896:Treatment Outcome; D059289:Vascular Stiffness / Q000187:drug effects*; D014665:Vasodilator Agents / Q000009:adverse effects / Q000627:therapeutic use*; D016277:Ventricular Function, Left / Q000187:drug effects; D016138:Walking
D014665:Vasodilator Agents
aorta; arterial pressure; blood pressure; heart failure; heart rate