Goal-directed Afterload Reduction in Acute Congestive Cardiac Decompensation Study
- Conditions
- Acute Heart Failure
- Interventions
- Drug: Goal-directed preload and afterload decrement
- Registration Number
- NCT00512759
- Lead Sponsor
- University Hospital, Basel, Switzerland
- Brief Summary
The purpose of this study is to determine whether an early goal-directed decrement of preload and afterload with a target systolic blood pressure of 90-110 mmHg by aggressive vasodilatation in patients with acute HF in the non-ICU setting is safe, and leads to a better clinical and economical outcome
- Detailed Description
Background: Heart failure (HF) is a chronic and progressive illness resulting from a variety of cardiac causes, including ischemic and valvular heart disease, dilatative cardiomyopathy or hypertension. HF may also develop suddenly, particularly as a complication of acute myocardial infarction or as an acute exacerbation in patients with previously compensated chronic HF. Acute HF requires immediate treatment that centers on reducing myocardial oxygen demand and augmenting forward blood flow by removal of excess fluid with diuretics and reduction of preload and afterload with vasodilatators. The aging of our population and the higher number of patients surviving acute myocardial infarctions have lead to a dramatic increase in the incidence and prevalence of HF, and obviously also on total cost burden of the disease. For multiple reasons including need for restrictive use of the limited number of ICU hospital beds the vast majority of elderly patients with acute HF are treated in a non-ICU setting. Unfortunately, the optimal treatment of acute HF in the non-ICU setting is not well defined. Pathophysiological considerations and preliminary data from the ICU setting suggest that aggressive venous and arterial vasodilation may improve short and long-term outcome.
Aim: To test the hypotheses that:
• An early goal-directed decrement of preload and afterload with a target systolic blood pressure of 90-110 mmHg by aggressive vasodilatation in patients with acute HF in the non-ICU setting is safe, and leads to a better clinical and economical outcome
Methods:
Design: Prospective, randomized, controlled, open label, interventional study Setting: University Hospital Basel Patients: Patients with acute HF not requiring ICU admission
Patients admitted to the emergency department with acute HF will be randomized to:
* Early goal-directed preload and afterload decrement using a fixed therapy schedule including sublingual and transdermal nitrates, and hydralazine, followed by rapid up-titration of ACE-inhibitors or AT-receptor blockers to achieve maximal vasodilatation with a target systolic blood pressure of 90-110 mmHg. All other elements of treatment will be according to the current guidelines of the European Society of Cardiology (ESC)
* Standard treatment of acute HF according to the current guidelines of the ESC.
Clinical Significance: Despite the clinical and economical importance of acute HF, the optimal treatment of acute HF is ill-defined. We strongly believe that our novel therapeutic strategy will significantly reduce morbidity, length of hospitalisation, and possibly mortality of affected patients. This would represent a first major step for an evidence-based management of this common condition. Documenting medical and economic benefit of a simple, safe, and inexpensive medical therapy in a randomised controlled clinical trial would provide evidence-based care for the majority of patients presenting with acute HF worldwide. All drugs applied in our strategy are off-patent and therefore relatively low-cost. Successful implication of our treatment algorithm has the potential to significantly reduce treatment costs.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 781
- Acute HF expressed by acute dyspnea New York Heart Association (NYHA) class III or IV, and a BNP-level ≥ 500 pg/ml. The diagnosis of acute HF is additionally based on typical symptoms and clinical findings, supported by appropriate investigations such as ECG, chest X-ray, and Doppler-echocardiography as recommended by current ESC guidelines on the diagnosis and treatment of acute HF
- Cardiopulmonary resuscitation < 7 days
- Cardiogenic shock, ST-elevation myocardial infarction, or other clinical conditions that require immediate ICU admission or urgent PTCA
- Systolic blood pressure lower than 100 mmHg at presentation
- Primary rhythmogenic cause of acute decompensation (ventricular tachycardia, reentry tachycardia, atrial fibrillation or atrial flutter with a ventricular rate exceeding 140 beats per minute)
- NSTEMI as primary diagnosis
- Severe aortic stenosis
- Adult congenital heart disease as primary cause of acute HF
- Hypertrophic obstructive cardiomyopathy
- Chronic kidney disease with creatinin levels > 250 µmol/l
- Bilateral renal artery stenosis
- Severe sepsis or other causes of high output failure
- Cirrhosis of the liver CHILD class C
- Previous adverse reactions to nitrates
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Intervention Goal-directed preload and afterload decrement Early goal-directed preload and afterload decrement using a fixed therapy schedule including sublingual or nitrospray and transdermal nitrates together with hydralazine, followed by rapid up-titration of ACE-inhibitors , AT-receptor blockers or neprilysin inhibitors/AT-receptor blockers to achieve maximal vasodilatation with a target systolic blood pressure of 90-110 mmHg. All other elements of treatment will be according to the current guidelines of the European Society of Cardiology (ESC)
- Primary Outcome Measures
Name Time Method Death or re-hospitalization from HF 180 days Death or re-hospitalization due to heart failure at 180 days
- Secondary Outcome Measures
Name Time Method All-cause mortality 180 days All-cause mortality at 180 days
HF re-hospitalization 180 days Re-hospitalization due to heart failure at 180 days
Trial Locations
- Locations (12)
National Transport Hospital "Tsar Boris III"
🇧🇬Sofia, Bulgaria
University Hospital Basel
🇨🇭Basel, BS, Switzerland
University Hospital Mainz
🇩🇪Mainz, Germany
5-th Multifunctional Hospital for Active Treatment
🇧🇬Sofia, Bulgaria
University Hospital "Tsaritsa Joanna-ISUL"
🇧🇬Sofia, Bulgaria
Kantonsspital Aarau
🇨🇭Aarau, Switzerland
Hospital de la Santa Creu i Sant Pau
🇪🇸Barcelona, Spain
Hospital Sao Paolo
🇧🇷São Paulo, Brazil
Hospital Universitari Germans Trias i Pujol
🇪🇸Badalona, Spain
Nuremberg Hospital
🇩🇪Nuremberg, Germany
Kantonsspital Luzern
🇨🇭Luzern, Switzerland
Kantonsspital St. Gallen
🇨🇭St. Gallen, Switzerland