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Early vasodilation in acute HF does not improve outcomes

ESC 2019
Results from the GALACTIC trial showed that early intensive vasodilation does not improve 180-day all-cause mortality and rehospitalisation in patients hospitalised for acute heart failure (HF), despite the use of individualised doses of various agents.

The GALACTIC trial hypothesised that early goal-directed therapy with maximal and persistent vasodilation would be able to achieve better clinical outcomes than standard care given to patients who were hospitalised for acute HF. A total of 781 patients were randomised to early goal-directed therapy or standard care until the moment of discharge. Early goal-directed therapy combined high and personalised doses of vasodilators including sublingual and transdermal nitrates, oral hydralazine for 48 hours to avoid tolerance to nitrates, and rapid up-titration of angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers. All other therapies including loop diuretic dose and duration, beta-blockers, aldosterone antagonists, and cardiac devices were administered according to current European Society of Cardiology guidelines and at the discretion of the treating physician. Primary endpoint of the trial was a composite of all-cause mortality or rehospitalisation for acute HF at 180 days. Secondary endpoints included quantitative assessment of dyspnoea at days 2 and 6. Participating patients were randomised at a median of 5 hours after presentation. Dyspnoea improved in both groups, and no significant between-group differences were observed. Almost all (99.7%) patients completed the clinical follow-up at 180 days. In total, 30.6%of patients in the early intensive vasodilation group met the primary endpoint versus 27.8%in the standard care group (adjusted HR1.07; 95% CI0.83 to 1.39; P=0.589). Results from predefined subgroup analyses demonstrated consistent results (according to age and left ventricular ejection fraction). Interestingly, a statistically significant interaction of the treatment effect was shown for gender, suggesting that early goal-directed therapy not only fails to benefit women, but it might even be harmful[1].

1. Mueller CE. GALACTIC -Goal-directed AfterLoad Reduction in Acute Congestive Cardiac Decompensation: a randomized controlled trial. FP Number 3178.ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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