Background

Titration of evidence-based medications, important for treating heart failure (HF), is often underdosed by symptom-guided treatment. The aim of this study was to investigate, using echocardiographic parameters, stroke volume and left ventricular (LV) filling pressure to guide up-titration of medications, increasing prognostic benefits.

Methods

A total of 765 patients with chronic HF and severely reduced LV ejection fractions (<35%), referred from 2008 to 2016, were prospectively studied. Echocardiographic guidance was performed in 149 patients. LV filling pressure was assessed by left atrial expansion index, and stroke volume was estimated from diameter and time-velocity integral in the LV outflow tract. Up-titration of evidence-based medications and adjustment for side effects or worsening clinical conditions according to those parameters were performed. Propensity score matching was used to match pairs of patients with (n = 110) or without (n = 110) echocardiographic guidance. End points were 4-year frequencies of HF hospitalization and all-cause mortality.

Results

During a mean follow-up time of 4.1 years, rates of adverse events were 58 (52.7%) with no echocardiographic guidance and 36 (32.7%) with echocardiographic guidance (P < .0001). Echocardiography provided effective guidance to reduce prescribing frequency and dose of diuretics and to promote evidence-based medication prescription. It reduced HF rehospitalization and all-cause mortality. By multivariate analysis, prognostic improvement was associated with up-titration of medications with echocardiographic guidance.

Conclusions

There was a statistically significant difference in long-term prognosis between propensity score–matched pairs of patients with chronic severe HF with and without echocardiographic guidance. These findings need further validation in large prospective clinical trials.

中文翻译：

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左心房扩张指数和中风量在管理慢性收缩性心力衰竭中的作用

背景

对治疗心力衰竭（HF）至关重要的循证药物的滴定通常在症状指导治疗中剂量不足。这项研究的目的是研究使用超声心动图参数，中风量和左心室（LV）充盈压来指导药物的上调剂量，从而增加预后的益处。

方法

前瞻性研究了2008年至2016年间共纳入的765例慢性HF和左室射血分数严重降低（<35％）的患者。149例患者进行了超声心动图指导。通过左心房扩张指数评估左室充盈压，并根据左室流出道的直径和时间-速度积分估算中风量。根据这些参数，对基于证据的药物进行了调整，并针对副作用或恶化的临床状况进行了调整。倾向得分匹配用于匹配有（n  = 110）或无（n  = 110）超声心动图指导的成对患者。终点为HF住院的4年频率和全因死亡率。

结果

在4.1年的平均随访时间内，无超声心动图指导的不良事件发生率为58（52.7％），有超声心动图指导的不良事件发生率为36（32.7％）（P  <.0001）。超声心动图提供了有效的指导，以减少利尿剂的处方频率和剂量，并促进循证用药处方。它降低了心衰再住院和全因死亡率。通过多变量分析，预后改善与超声心动图指导下药物调高有关。

结论

在有和没有超声心动图指导的情况下，倾向评分匹配的慢性重型HF患者之间的长期预后有统计学差异。这些发现需要在大规模的前瞻性临床试验中得到进一步的验证。