Invasive hemodynamic monitoring

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Based upon the results of the ESCAPE trial, there is no benefit in clinical outcomes associated with the routine use of a pulmonary artery line in patients with decompensated CHF.

Invasive Monitoring

Supportive Trial Data

The ESCAPE trial (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness), was the first large, multicenter, randomized controlled trial that enrolled 433 patients across 26 sites, to determine the safety of pulmonary artery catheter (PAC) or Swan-Ganz catheter use to improve clinical outcomes in patients hospitalized with severe symptomatic and recurrent heart failure. Off the total 433 patients enrolled, 218 patients were randomized to clinical assessment alone (clinical arm) and the remaining 215 were randomized to both PAC and clinical assessment (PAC arm); with almost all patients being treated with loop diuretics (98%), ACE inhibitors (79%), beta-blockers (62%), and spironolactone (51%) and only a small percentage received inotropes (15%) and intravenous vasodilators (8%) at the time of randomization. At 6-month follow up, the primary endpoint achieved was identical and non-significant among both the arms with an overall mortality of 19%. Thus, the study concluded no benefit demonstrated with the use of PAC for the improvement of clinical outcomes in patients with advanced heart failure.

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)

Invasive Hemodynamic Monitoring in Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C) "

Class III (No Benefit)

"1. Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended. (Level of Evidence: B) "

Class IIa

"1. Invasive hemodynamic monitoring can be useful for carefully selected patients with acute heart failure who have persistent symptoms despite empiric adjustment of standard therapies, and (Level of Evidence: C)

"a. Whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain,"

"b. Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy,"

"c. Whose renal function is worsening with therapy,"

"d. Who require parenteral vasoactive agents or"

"e. Who may need consideration for advanced device therapy or transplantation. "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

External Links

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult