Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial

• Published in: Circulation. Heart failure Vol. 1; no. 3; pp. 170 - 177
• Main Authors: Drazner, Mark H, Hellkamp, Anne S, Leier, Carl V, Shah, Monica R, Miller, Leslie W, Russell, Stuart D, Young, James B, Califf, Robert M, Nohria, Anju
• Format: Journal Article
• Language: English
• Published: United States 01.09.2008
• Subjects: Aged; Cardiac Catheterization - methods; Female; Heart Failure - diagnosis; Heart Failure - physiopathology; Hemodynamics - physiology; Humans; Male; Middle Aged; Prognosis; Pulmonary Wedge Pressure - physiology; ROC Curve; Stroke Volume - physiology; Ventricular Function, Left - physiology; heart failure; hemodynamics; history and physical examination
• ISSN: 1941-3289; 1941-3297; 1941-3297
• DOI: 10.1161/CIRCHEARTFAILURE.108.769778

We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure (HF). The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps due to lack of evidence for utility. We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the ESCAPE trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure (RAP) was <8 mm Hg in 82% of patients with RAP estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated RAP > or =12 mm Hg (odds ratio [OR] 4.6; P<0.001) and orthopnea > or =2 pillows (OR 3.6; P<0.05) were associated with pulmonary capillary wedge pressure (PCWP) > or =30 mm Hg. Estimated cardiac index did not reliably reflect measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 vs. 2.0 L/min/m(2); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization. In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.