Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure

Narang, Nikhil; Chung, B.; Nguyen, A.; Kalathiya, Rohan; Laffin, Luke J.; Holzhauser, Luise; Ebong, I.; Besser, Stephanie; Imamura, Teruhiko; Smith, Bryan; Kalantari, S.; Raikhelkar, J.; Kim, Gene; Jeevanandam, Valluvan; Burkhoff, Daniel; Sayer, Gabriel; Uriel, Nir

doi:10.1016/j.cardfail.2019.08.004

Cited by 39 publications

(19 citation statements)

References 19 publications

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“…Evaluation and monitoring of fluid excess status in patients admitted for ADHF is currently based on clinical history, physical examination, chest X-ray, and natriuretic peptides. 5 However, all these have inherent substantial inter-observer variability and may be non-specific, 6,16 and plasma levels of biomarkers have a limited capacity to assess quantitatively the extent of fluid retention. 17 Right heart catheterization and chest-computed tomography are much more accurate Abbreviations: 6MWT, 6 min walk test; ACE inhibitor, angiotensin converting-enzyme inhibitor; ARB, angiotensin-receptor blocker; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; eGFR, estimated glomerular filtration rate (Modification of Diet in Renal Disease Study formula); HF, heart failure; HFmrEF, heart failure with mid-range ejection fraction; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; LUS, lung ultrasound; Minnesota LWHF, Minnesota Living With Heart Failure quality of life scale; NT-proBNP, amino terminal pro brain natriuretic peptide; NYHA, New York Heart Association.…”

Section: Prognosis Of Residual Congestion In Heart Failurementioning

confidence: 99%

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure

et al. 2020

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Aims Residual pulmonary congestion at hospital discharge can worsen the outcomes in patients with heart failure (HF) and can be detected by lung ultrasound (LUS). The aim of this study was to analyse the prevalence of subclinical pulmonary congestion at discharge and its impact on prognosis in patients admitted for acute HF. Methods and results This is a post-hoc analysis of the LUS-HF trial. LUS was performed by the investigators in eight chest zones with a pocket device. Physical exam was subsequently performed by the treating physicians. Primary outcome was a combined endpoint of rehospitalization, unexpected visit for HF worsening or death at 6month follow-up. Subclinical pulmonary congestion at discharge was defined as the presence of ≥5 B-lines in LUS in absence of rales in the auscultation employing the area under the ROC curve. At discharge, 100 patients (81%) did not show clinical signs of pulmonary congestion. Of these, 41 had ≥5 B-lines. Independent factors related with the presence of subclinical pulmonary congestion were anaemia, higher New York Heart Association (NYHA) class, and N terminal pro brain natriuretic peptide (NT-proBNP). After adjusting by propensity score analysis including age, renal insufficiency, atrial fibrillation, NYHA class, NT-proBNP levels, clinical congestion, and the trial intervention, the presence of subclinical pulmonary congestion at discharge was a risk factor for the occurrence of the primary outcome (hazard ratio 2.63; 95% confidence interval: 1.08-6.41; P = 0.033). Conclusions Up to 40% of patients considered 'dry' according to pulmonary auscultation presents subclinical congestion at hospital discharge that can be detected by LUS and implies a worse prognosis at 6month follow-up. Comorbidities, high values of natriuretic peptides, and higher NYHA class are the factors related with its presence.

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Section: Prognosis Of Residual Congestion In Heart Failurementioning

confidence: 99%

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure

et al. 2020

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“…7% (N = 7) of patients in total had percutaneous mechanical support devices (N = 6, Intra-aortic balloon pump; N = 1, Impella) with inotropes and/or vasopressors prior to RHC. Median RA pressure was 15.5 (10,22) ; PCWP (21,35) vs. 1.1 (0.7, 1.5), p = .001]. There were no other significant differences between hemodynamic variables observed between the two groups.…”

Section: Resultsmentioning

confidence: 82%

“…More liberal use of hemodynamic assessment may be needed to better classify NYHA Class III‐IV patients presenting with ADHF 37 . Early RHC should be considered in these patients even when clinical assessment, and particularly the physical exam, is not otherwise indicative of cardiogenic shock 10 …”

Section: Discussionmentioning

confidence: 99%

“…This was a retrospective analysis of an invasive hemodynamics registry of advanced heart failure patients where providers were tasked to predict hemodynamics prior to right heart catheterization (RHC). 10 Data for this current analysis were abstracted from this registry. The study took place at the University of Chicago Medical Center with patient data was collected between 2016 and 2018.…”

Section: Methodsmentioning

confidence: 99%

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Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure

Narang

Cruz

Imamura

et al. 2021

Clinical Cardiology

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Background Elevated lactic acid (LA) levels carry a poor prognosis in patients with shock. Data are lacking on the significance of LA levels in patients with acute decompensated heart failure (ADHF). Hypothesis This study assessed the relationship between LA levels, hemodynamics and clinical outcomes. Methods This was a retrospective analysis of registry data of 100 advanced heart failure patients presenting for right heart catheterization (RHC) for concern of ADHF. LA levels (normal ≤2.1 mmol/L) were obtained prior to RHC; no significant changes in therapy were made between LA collection and RHC. Results Median age was 58 (47.3, 64.8) years; 57% were receiving inotropes prior to RHC. Median pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were 28 (21, 35) mmHg and 2.0 (1.7, 2.5) L/min/m2, respectively. Eighty patients had normal LA prior to RHC. There was no correlation between LA levels and PCWP (R = 0.09, p = .38); 63% of the normal LA group had a PCWP >24 mmHg. There was a moderate inverse correlation between LA and CI (R = − 0.40; p < .001); 58% of the normal LA group had a CI <2.2 L/min/m2. Thirty‐day survival free of death/hospice, inotrope dependence, progression to heart transplant/left‐ventricular assist device implant was comparable between the normal and elevated LA groups (28% vs. 20%; p = .17). Conclusion In patients presenting with ADHF, normal LA levels do not exclude the presence of depressed CI (a hemodynamic criteria for cardiogenic shock) and may not offer accurate risk stratification. Invasive hemodynamics should not be delayed based on normal LA levels alone.

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“…First, many patients may have residual abnormal hemodynamics following LVAD support. Second, such abnormal hemodynamics are sometimes a challenge to clinically detect by physical examination alone [17]. Third, as discussed below, such abnormal hemodynamics are associated with future adverse events following LVAD implantation.…”

Section: Hemodynamics and Adverse Eventsmentioning

confidence: 99%

Implication of Hemodynamic Assessment during Durable Left Ventricular Assist Device Support

Imamura

Narang

2020

Medicina

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Durable left ventricular assist device therapy has improved survival in patients with advanced heart failure refractory to conventional medical therapy, although the readmission rates due to device-related comorbidities remain high. Left ventricular assist devices are designed to support a failing left ventricle through relief of congestion and improvement of cardiac output. However, many patients still have abnormal hemodynamics even though they may appear to be clinically stable. Furthermore, such abnormal hemodynamics are associated with an increased risk of future adverse events including recurrent heart failure, gastrointestinal bleeding, stroke, and pump thrombosis. Correction of residual hemodynamic derangements post-implantation may be a target in improving longitudinal clinical outcomes during left ventricular assist device support. Automatic and timely device speed adjustments considering a patients’ hemodynamic status (i.e., with a smart pump) are potential improvements in forthcoming devices.

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Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure

Cited by 39 publications

References 19 publications

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure

Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure

Implication of Hemodynamic Assessment during Durable Left Ventricular Assist Device Support

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