Hemodynamic Goals Are Relevant

The diversity of patient profiles and responses precludes a one-size-fits-all approach to heart failure. The randomized trials have provided us with some therapies that must be tried and others that can be tried. Offering significant although small benefits averaged over a population, these therapies are bolts of fabric stacked beside a tailor’s mannequin, the typical trial subject. The sequential patching of different medications in the order of their investigation, however, is not likely to yield the best regimen for any patient. There should be little disagreement on the principle of tailoring therapies for individuals, but what measurements should be taken? The primary goal for asymptomatic and mildly symptomatic heart failure is to prevent or delay disease progression. Once symptoms and the risk of mortality dominate, the goals are to relieve symptoms and prolong survival. It has been proposed that hemodynamic goals are not appropriate in the care of these patients with heart failure. To construct the clearest case to the contrary, this discussion will focus on patients with advanced heart failure as those in whom hemodynamic abnormalities are most apparent (although a case can also be made for contributions of early rises in intracardiac pressures, blunting of natriuretic peptide responses, fluid retention, and valvular regurgitation and disease progression). Advanced heart failure will be defined here in those patients with dilated ventricles and low ejection fraction who have persistent or recurrent symptoms limiting daily life (New York Heart Association class III and IV)1 despite initiation of angiotensin-converting enzyme inhibitors, β-blockers, and diuretics that may include spironolactone. Most patients will have had a prior hospitalization for heart failure. Therapy is currently outlined around a pattern from survival trial protocols. The regimen is then tailored further to symptoms and signs, which themselves often reflect hemodynamic changes in heart failure, although in most …