Physician-Directed Patient Self-Management of Left Atrial Pressure in Advanced Chronic Heart Failure

Abstract

Background-Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. We conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure. Methods and Results-Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16 [95% confidence interval 0.04 to 0.68], Pϭ0.012). Mean daily left atrial pressure fell from 17.6 mm Hg (95% confidence interval 15.8 to 19.4 mm Hg) in the first 3 months to 14.8 mm Hg (95% confidence interval 13.0 to 16.6 mm Hg; Pϭ0.003) during pressure-guided therapy. The frequency of elevated readings (Ͼ25 mm Hg) was reduced by 67% (PϽ0.001). There were improvements in New York Heart Association class (Ϫ0.7Ϯ0.8, PϽ0.001) and left ventricular ejection fraction (7Ϯ10%, PϽ0.001). Doses of angiotensin-converting enzyme/angiotensin-receptor blockers and ␤-blockers were uptitrated by 37% (PϽ0.001) and 40% (PϽ0.001), respectively, whereas doses of loop diuretics fell by 27% (Pϭ0.15). Conclusions-Physician-directed patient self-management of left atrial pressure has the potential to improve hemodynamics, symptoms, and outcomes in advanced heart failure. Clinical Trial Registration Information-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00547729.

Rehospitalization for Heart Failure

“…54 Wireless transmission of directly measured left atrial pressures to a handheld device has also been used to empower patients to self-adjust diuretics with guidance from the heart failure team, thus tightening the feedback loop around the patient. 55 For patients at high risk for recurrent decompensation, or those with precarious balance between volume overload and azotemia, this approach may someday allow optimal titration of diuretics in patients with heart failure in much the same way that insulin is now self-adjusted to daily fingerstick glucose measurements by those with diabetes.…”

Evaluation of a Community Health Service Center-Based Intervention Program for Managing Chronic Heart Failure

“…Thus, preparing a more specific and tailored CHF management plan was possible for patients with complex needs and therefore, leading to better clinical outcome. However, in the current CHSC-based study, care delivery for CHF patients was led by general practitioners or community nurses, unlike cardiac nurses, clinical pharmacists or cardiologists in hospital-based trials (27). These private practitioners and nurses were working and/or living in the same community as CHF patients for a long time.…”

Remote Monitoring of Heart Failure Patients

“…16 Direct left atrial pressure monitoring with an implantable wireless technology has been validated in humans by Ritzwema et al 17 and studied as a strategy to provide physician guidance of patient self management in the HOMEOSTASIS trial. 18 An ongoing trial called LAPTOP 19 is studying the same technology in NYHA-III patients (low and preserved ejection fraction) who are on optimal medical therapy; the objective is to assess if a physiciandirected patient self-management system guided by left atrial pressure will reduce HF hospitalizations. The study is expected to be complete by August 2013.…”