Chronic Ambulatory Intracardiac Pressures and Future Heart Failure Events

Abstract

Background-Intracardiac pressures in heart failure (HF) have been measured in patients while supine in the hospital but change at home with posture and activity. The optimal level of chronic ambulatory pressure is unknown. This analysis compared chronic intracardiac pressures to later HF events and sought a threshold above which higher pressures conferred worse outcomes. Methods and Results-Median pressures were measured every 24 hours from continuous 8-minute segments for 6 months after implantation of hemodynamic monitors in 261 patients with New York Heart Association class III-IV HF in the Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure Study. Baseline and chronic daily medians of estimated pulmonary artery diastolic, right ventricular systolic, and right ventricular end-diastolic pressures were compared with HF event rate. The group median for chronic 24-hour estimated pulmonary artery diastolic pressure was 28 mm Hg (excluding 7 days before and after events). Despite weight-guided management, events occurred in 100 of 261 (38%) patients. Event risk increased progressively with higher chronic 24-hour estimated pulmonary artery diastolic pressure, from 20% at 18 mm Hg to 34% at 25 mm Hg and 56% at 30 mm Hg, with similar relations for right ventricular pressures. Among patients with baseline day median estimated pulmonary artery diastolic pressures of Ն25 mm Hg, event risk was 1.10/6 mo when they remained chronically Ն25 mm Hg, but risk fell to 0.47 when 24-hour pressures declined to Ͻ25 mm Hg for more than half of the days. Conclusions-Despite current management, many patients with advanced HF live on a plateau of high filling pressures from which later events occur. This risk is progressively higher with higher chronic ambulatory pressures. It is not known whether more targeted intervention could maintain lower chronic ambulatory pressures and better outcomes. (Circ Heart Fail. 2010;3:580-587.)

Rehospitalization for Heart Failure

“…16 Data from trials of implantable hemodynamic monitors confirm that the risk for heart failure events is tightly coupled to the degree of chronic filling pressure elevation, with progressively higher risk once the median 24-hour pulmonary artery diastolic pressure rises Ͼ18 mm Hg. 17 Chun et al 7 have elegantly outlined a 3-phase terrain of lifetime risk for readmission based on analysis of a cohort of 8543 newly discharged Canadian patients with heart failure (see Figure 1). 18 In this community-dwelling population, 30% of all cardiovascular readmissions occurred within the first 2 months of hospital discharge, and 50% occurred within the 2 months before death, with much lower admission rates (15%-20%) observed in the intercurrent plateau phase.…”

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

“…[25] This finding is supported by studies showing changes in heart rate variability occurring weeks prior to presentation for AHF, a time during which cardiac filling pressures begin to rise, in the absence of a change in weight, and prior to the development of symptoms. [26] Thus, while symptoms drive most patients with HF to seek treatment, there is at least a moderate degree of discordance between symptoms, cardiac filling pressures, and intravascular volume.…”

Left Ventricular Dysfunction With Pulmonary Hypertension

“…Hemodynamic worsening is characteristic of acute HF; however, few studies have described the changes over time and the short-and longterm implications of hemodynamics in acute HF. In ambulatory patients, dynamic changes in PAP predict acute HF events, 108 and elevations in 24-hour filling pressures precede episodes of decompensation in both HFrEF and HFpEF patients. 109 Aronson et al 38 reported that before treatment, among 242 patients, only 2 (0.83%) had normal PAP (defined as RHC mPAP ≤25 mm Hg); 59.1% had passive PH (mPAP >25 mm Hg, PCWP >15 mm Hg, and PVR ≤3 WU); and 40.1% had reactive PH (mPAP >25 mm Hg, PCWP >15 mm Hg, and PVR >3 WU).…”