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CLINICAL STUDY: HEART FAILURE

Exhaled nitric oxide: a marker of pulmonary hemodynamics in heart failure

Joshua M. Hare, MD, FACC^*,*, Geoffrey C. Nguyen, MD^*, Anthony F. Massaro, MD, Jeffrey M. Drazen, MD, Lynne W. Stevenson, MD, FACC, Wilson S. Colucci, MD, FACC, James C. Fang, MD, FACC, Wendy Johnson, MD, FACC, Michael M. Givertz, MD, FACC and Caroline Lucas, MD

^* Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Brigham and Women’s Hospital, Boston, Massachusetts, USA
Boston University, Boston, Massachusetts, USA

Manuscript received June 11, 2001; revised manuscript received May 17, 2002, accepted June 19, 2002.

^* Reprint requests and correspondence: Dr. Joshua M. Hare, Johns Hopkins Hospital, Division of Cardiology, 600 North Wolfe Street, Carnegie 568, Baltimore, Maryland 21287, USA.
jhare{at}mail.jhmi.edu

OBJECTIVES: We sought to test the hypothesis that patients with decompensated heart failure (HF) lose a compensatory process whereby nitric oxide (NO) maintains pulmonary vascular tone.

BACKGROUND: Exhaled nitric oxide (eNO) partially reflects vascular endothelial NO release. Levels of eNO are elevated in patients with compensated HF and correlate inversely with pulmonary artery pressures (PAP), reflecting pulmonary vasodilatory activity.

METHODS: We measured the mean mixed expired NO content of a vital-capacity breath using chemiluminescence in patients with compensated HF (n = 30), decompensated HF (n = 7) and in normal control subjects (n = 90). Pulmonary artery pressures were also measured in patients with HF. The eNO and PAP were determined sequentially during therapy with intravenous vasodilators in patients with decompensated HF (n = 7) and in an additional group of patients with HF (n = 13) before and during administration of milrinone.

RESULTS: The eNO was higher in patients with HF than in control subjects (9.9 ± 1.1 ppb vs. 6.2 ± 0.4 ppb, p = 0.002) and inversely correlated with PAP (r = –0.81, p < 0.00001). In marked contrast, patients with decompensated HF exhibited even higher levels of eNO (20.4 ± 6.2 ppb) and PAP, but there was a loss of the inverse relationship between these two variables. During therapy (7.3 ± 6 days) with sodium nitroprusside and diuresis, hemodynamics improved, eNO concentrations fell (11.2 ± 1.2 ppb vs. before treatment, p < 0.05), and the relationship between eNO and PAP was restored. After milrinone, eNO rose proportionally with decreased PAP (p < 0.05).

CONCLUSIONS: Elevated eNO may reflect a compensatory circulatory mechanism in HF that is lost in patients with clinically decompensated HF. The eNO may be an easily obtainable and quantifiable measure of the response to therapy in advanced HF.

Abbreviations and Acronyms   cGMP   cyclic guanosine 3',5'-monophosphate   eNO   exhaled nitric oxide   FEV1   forced expiratory volume in 1 s   FVC   forced vital capacity   HF   heart failure   L-NMMA   NG-monomethyl-L-arginine   NO   nitric oxide   NYHA   New York Heart Association   PAP   pulmonary artery pressure   PVR   pulmonary vascular resistance   SNP   sodium nitroprusside   SVR   systemic vascular resistance

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