Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness

doi:10.1001/jama.294.13.1625

Cited by 1,301 publications

(264 citation statements)

References 41 publications

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“…As a result, patients are now less likely to require hospitalization for the once‐typical course of decompensation reversed with simple intravenous diuresis 15, 16, 17, 18. The contemporary population of hospitalized HF patients is now older, with a longer duration of disease and a larger burden of right HF, cardiorenal syndrome, and noncardiac comorbidities.…”

Section: Introductionmentioning

confidence: 99%

Reasons for Guideline Nonadherence at Heart Failure Discharge

Gilstrap

Stevenson

Small

et al. 2018

JAHA

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BackgroundCardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline‐directed medical therapy, this study aims to measure and explain apparent deviations in heart failure (HF) guideline adherence by clinicians at hospital discharge and describe any impact on readmission rates.Methods and ResultsThe extent of decongestion and prescription of neurohormonal therapy were recorded prospectively for 226 HF discharges, including 132 (58%) from an academic hospital and 94 (42%) from a community hospital. Among all discharges, 25% were discharged with residual congestion (30% academic versus 18% community, P=0.070). Among discharges of patients with HF with reduced ejection fraction, 37% (45% academic versus 18% community, P<0.001) were discharged without β‐blocker therapy or with lower doses than at admission. Moreover, 46% of patients with HF with reduced ejection fraction (48% academic versus 39% community, P=0.390) were discharged without an angiotensin‐converting enzyme inhibitor or angiotensin II receptor blocker or with lower doses than at admission. Renal dysfunction was the most common reason for discharge with congestion, and hypotension the most common reason for discharge with no or decreased neurohormonal therapy. There was a trend toward higher 90‐day readmission rates after discharge with residual congestion.ConclusionsClinicians frequently deviate from guidelines in both academic and community hospitals; however, this deviation may not always indicate poor quality. Application of guidelines recommended for stable populations is increasingly limited for hospitalized patients by hypotension, renal dysfunction, and inotrope use. Patients with renal dysfunction, hypotension, and recent inotrope use merit further study to determine best practices and possibly to adjust quality metrics for HF severity.

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Section: Introductionmentioning

confidence: 99%

Reasons for Guideline Nonadherence at Heart Failure Discharge

Gilstrap

Stevenson

Small

et al. 2018

JAHA

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“…20 In contrast with the ESCAPE trial, this pilot study evaluated a higher-risk population with LCOS and renal insufficiency. However, we did not find a difference between the groups with and without a pulmonary artery catheter.…”

Section: ■ Discussionmentioning

confidence: 99%

Goal-directed therapy for decompensated heart failure and renal dysfunction. A pilot randomized clinical trial

Bastos¹,

Ferri²,

Lima³

et al. 2016

Medical Express

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OBJECTIVES:Acute heart failure is associated with low cardiac output syndrome and renal dysfunction. However, it is not known whether a goal-directed protocol guided by tightly controlled hemodynamic variables, including pulmonary artery catheter, will safely improve clinical renal dysfunction markers in these patients when compared to a less invasive approach. METHODS: Pilot, randomized clinical trial aimed at patients with known heart failure, low cardiac output syndrome and renal dysfunction with less than 48 hours from onset. We randomized two groups: (a) goal-directed therapy monitored with pulmonary artery catheter and (b) conventional therapy with central venous catheter. Hemodynamic parameters, venous oxygen saturation, serum lactate, fluid repositions and vasoactive drugs were compared considering renal function improvement after 72 hours as the primary study endpoint. We included 15 goal-directed therapy and 16 conventional therapy patients. The study has assessed patients on baseline looking for significant improvement at 72 hours of the following parameters in the goal-directed therapy and conventional therapy groups: urine output, serum creatinine, venous oxygen saturation and serum lactate. RESULTS: Baseline characteristics were similar in both groups. In the first 24 hours there was a lower volume of fluid reposition in the goal-directed therapy group, although 72 hours later such reposition was equivalent. The use of inotropic agents was similar between groups. There was an improvement to the renal function and the hemodynamic parameter in both study groups. CONCLUSIONS: The option for the protocol with pulmonary artery catheter setting is justified only if there is clinical evidence of serious pulmonary congestion associated to low peripheral perfusion.

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“…In the ESCAPE trial, AHF treatment guided by pulmonary artery catheter was non‐useful compared with conventional therapy 26. It is noteworthy, however, that physicians treating ESCAPE trial patients had central venous pressure measurements and echocardiograms available on a daily basis in both groups, although their role for guiding treatment was not clearly reported.…”

Section: Discussionmentioning

confidence: 99%

Focused echocardiography and lung ultrasound protocol for guiding treatment in acute heart failure

et al. 2017

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AimsThere is little evidence‐based therapy existing for acute heart failure (AHF), hospitalizations are lengthy and expensive, and optimal monitoring of AHF patients during in‐hospital treatment is poorly defined. We evaluated a rapid cardiothoracic ultrasound (CaTUS) protocol, combining focused echocardiographic evaluation of cardiac filling pressures, that is, medial E/e′ and inferior vena cava index, with lung ultrasound (LUS) for guiding treatment in hospitalized AHF patients.Methods and resultsWe enrolled 20 consecutive patients hospitalized for AHF, whose in‐hospital treatment was guided using the CaTUS protocol according to a pre‐specified treatment protocol targeting resolution of pulmonary congestion on LUS and lowering cardiac filling pressures. Treatment results of these 20 patients were compared with those of a standard care sample of 100 patients, enrolled previously for follow‐up purposes. The standard care sample had CaTUS performed daily for follow‐up and received standard in‐hospital treatment without ultrasound guidance. All CaTUS exams were performed by a single experienced sonographer. The CaTUS‐guided therapy resulted in significantly larger decongestion as defined by reduction in symptoms, cardiac filling pressures, natriuretic peptides, cumulative fluid loss, and resolution of pulmonary congestion (P < 0.05 for all) despite a shorter mean length of hospitalization. Congestion parameters were significantly lower also at discharge (P < 0.05 for all), without any significant difference in these parameters on admission. The treatment arm displayed better survival regarding the combined endpoint of 6 month all‐cause death or AHF re‐hospitalization (log rank P = 0.017). No significant difference in adverse events occurred between the groups.ConclusionsThe CaTUS‐guided therapy for AHF resulted in greater decongestion during shorter hospitalization without increased adverse events in this small pilot study and might be associated with a better post‐discharge prognosis.

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Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness

Cited by 1,301 publications

References 41 publications

Reasons for Guideline Nonadherence at Heart Failure Discharge

Reasons for Guideline Nonadherence at Heart Failure Discharge

Goal-directed therapy for decompensated heart failure and renal dysfunction. A pilot randomized clinical trial

Focused echocardiography and lung ultrasound protocol for guiding treatment in acute heart failure

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