Refractory acute decompensated heart failure: an observational study on a noninvasive hemodynamic monitoring system aimed at improving the therapeutic approach.

Background Inotropic agents should only be administered in acute decompensated heart failure (ADHF) refractory to vasodilators at optimal doses because they are associated with adverse outcome. In this setting a noninvasive hemodynamic monitoring system (NHMS) could be useful for optimizing treatment. Methods Inclusion criteria: advanced chronic heart failure, ejection fraction 30% or less, admission for ADHF with systolic blood pressure 115 mmHg or less and inadequate response at 48 h of therapy. Patients were evaluated with a NHMS: with vascular systemic resistance (VSR) greater than 1500 dyne x s/cm(5) we used vasodilators at increasing doses, with VSR less than 1500 and cardiac index (CI) less than 2.4 l/min per m(2) inotropic agents were used. Results The study population consisted of 20 patients (mean age 67 +/- 12 years) with ejection fraction 20 +/- 7%. After 48 h of clinical-guided therapy, none of the patients achieved VSR 1500 or less, and 12 patients had a CI less than 2.4 l/min per m(2). After hemodynamic-guided therapeutic optimization there was a significant reduction of dyspnea at rest (7.7 +/- 1.25 versus 2.44 +/- 1.33 on the 10-point Likert scale, P < 0.001) and 'cold' presentation (12 patients before and 1 patient after, P = 0.0004). Daily urinary volume was higher (1217 +/- 369 versus 2260 +/- 797 ml, P = 0.001) without renal function deterioration (creatinine 1.56 +/- 0.52 versus 1.34 +/- 0.61 mg/dl, P = 0.012). The nitroprusside dosing was increased after NHMS (0.13 +/- 0.19 versus 0.4 +/- 0.310 mu g/kg per min, P = 0.044), whereas doses of inotropic agents, diuretics and beta-blockers did not change significantly. Conclusions In refractory ADHF a NHMS improves significantly symptoms and renal function, with a better use of vasodilators. J Cardiovasc Med 11:655-661 (C) 2010 Italian Federation of Cardiology.