In Reply Dr Kumar brings up 3 relevant queries regarding the ROSE trial: (1) whether future clinical trials in acute heart failure should target heart failure with preserved ejection fraction and heart failure with reduced ejection fraction separately; (2) the relevance of cystatin C as a surrogate end point; and (3) whether the advanced renal disease in the study population makes them nonresponders to any therapeutic measure.
In the ROSE trial, there was a suggestion of differential treatment effects according to the ejection fraction in both the low-dose dopamine and low-dose nesiritide strategies. Compared with patients with reduced ejection fraction, those with heart failure and preserved ejection fraction may have experienced greater decreases in blood pressure and lesser increases in stroke volume in response to the decrease in systemic vascular resistance with low-dose dopamine or nesiritide,1 likely due to differential ventricular vascular properties. We agree with Kumar that these findings suggest that further investigation of other acute heart failure therapies may need to assess the potential for differential responses in heart failure with preserved vs reduced ejection.
Horng H. Chen, Margaret M. Redfield. Dopamine vs Nesiritide for Acute Heart Failure With Renal Dysfunction—Reply. JAMA. 2014;311(15):1565–1566. doi:10.1001/jama.2014.2462