Clinical Trials
Clinical Impact of Changes in Hemodynamic Indices of Contractile Function During Treatment of Acute Decompensated Heart Failure

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Abstract

Background

The objective of this work was to determine the impact of improving right ventricular versus left ventricular stroke work indexes (RVSWI vs LVSWI) during therapy for acute decompensated heart failure (ADHF).

Methods and Results

Cox proportional hazards regression and logistic regression were used to analyze key factors associated with outcomes in 175 patients (mean age 56.7 ± 13.6 years, 29.1% female) with hemodynamic data from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial. In this cohort, 28.6% and 69.7%, respectively, experienced the outcomes of death, transplantation, or ventricular assist device implantatation (DVADTX) and DVADTX or HF rehospitalization (DVADTXHF) during 6 months of follow-up. Increasing RVSWI (ΔRVSWI) from baseline to discharge was associated with a decrease in DVADTXHF (hazard ratio [HR] 0.923, 95% confidence interval [CI] 0.871–0.979) per 0.1 mm Hg⋅L⋅m−2 increase); however, increasing LVSWI (ΔLVSWI) had only a nonsignificant association with decreased DVADTXHF (P = .11) In a multivariable model, patients with ΔRVSWI ≤1.07 mm Hg⋅L⋅m−2 and ΔLVSWI ≤4.57 mm Hg⋅L⋅m−2 had a >2-fold risk of DVADTXHF (HR 2.05, 95% CI 1.23–3.41; P = .006).

Conclusion

Compared with left ventricular stroke work, increasing right ventricular stroke work during treatment of ADHF was associated with better outcomes. The results promise to inform optimal hemodynamic targets for ADHF.

Section snippets

Methods

The ESCAPE trial was a National Heart, Lung, and Blood Institute–sponsored multicenter trial conducted at 26 sites from 2000 to 2003. A total of 433 patients were randomized to receive therapy guided by clinical assessment alone or by clinical assessment and data from a pulmonary artery catheter. Of the 215 patients randomized to pulmonary artery catheter, 175 (81.4%) had complete hemodynamic and follow-up data at 6 months and were included in the present analysis. Hemodynamic measurements from

Results

The database of the ESCAPE trial contains records for 433 patients. Of these, 215 were assigned to pulmonary artery catheter–guided therapy in addition to clinical assessment. A total of 175 patients had complete invasive hemodynamics at baseline and follow-up and were included in the present analysis. The median age of patients was 56.7 ± 13.6 years old, 29.1% of the patients were female, and 59.4% had race reported as “white.” Table 1 presents the baseline characteristics of the study

Discussion

The present analysis investigated the relationship between changes in hemodynamic indexes of contractile function during pulmonary artery catheter–guided therapy in ADHF and the clinical outcomes at 6 months with the use of the ESCAPE trial database. We report 2 main findings. First, we found that increasing change in RVSWI from baseline to pulmonary artery catheter removal was associated with improved outcomes independently from the change in LVSWI. This significant interaction between the

Study Limitations

The results of this study are based on a retrospective analysis of a relatively small number of patients; therefore, further confirmatory studies are indicated based on a prospective evaluation of a larger group of patients with ADHF. In addition, the limitations of our study are tied to the inherent limitations of the ESCAPE trial design, such as the need for more precisely defined treatment strategies in response to the hemodynamic information obtained. There was also considerable variation

Conclusion

Compared with increasing LV stroke work, increasing RV stroke work during treatment of ADHF has a stronger association with improved clinical outcomes after discharge. Our results promise to inform optimal hemodynamic targets for the treatment of decompensated heart failure in the modern era.

Disclosures

None.

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Funding: Dr. Bilchick is supported by the National Institutes of Health (R03 HL135463).

This paper was handled by a Guest Editor for all reviewing stages and final decision process.

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