Value of clinician assessment of hemodynamics in advanced heart failure

the ESCAPE trial.

Mark H. Drazner, Anne S. Hellkamp, Carl V. Leier, Monica R. Shah, Leslie W. Miller, Stuart D. Russell, James B. Young, Robert M. Califf, Anju Nohria

Research output: Contribution to journalArticle

127 Citations (Scopus)

Abstract

BACKGROUND: We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure (HF). The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps due to lack of evidence for utility. METHODS AND RESULTS: We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the ESCAPE trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure (RAP) was <8 mm Hg in 82% of patients with RAP estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated RAP > or =12 mm Hg (odds ratio [OR] 4.6; P<0.001) and orthopnea > or =2 pillows (OR 3.6; P<0.05) were associated with pulmonary capillary wedge pressure (PCWP) > or =30 mm Hg. Estimated cardiac index did not reliably reflect measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 vs. 2.0 L/min/m(2); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization. CONCLUSIONS: In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.

Original languageEnglish (US)
Pages (from-to)170-177
Number of pages8
JournalCirculation. Heart failure
Volume1
Issue number3
DOIs
StatePublished - Sep 2008

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Heart Failure
Hemodynamics
Atrial Pressure
Odds Ratio
Venous Pressure
Routine Diagnostic Tests
Physical Examination
Neck
Perfusion
History
Regression Analysis
Pressure

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Value of clinician assessment of hemodynamics in advanced heart failure : the ESCAPE trial. / Drazner, Mark H.; Hellkamp, Anne S.; Leier, Carl V.; Shah, Monica R.; Miller, Leslie W.; Russell, Stuart D.; Young, James B.; Califf, Robert M.; Nohria, Anju.

In: Circulation. Heart failure, Vol. 1, No. 3, 09.2008, p. 170-177.

Research output: Contribution to journalArticle

Drazner, MH, Hellkamp, AS, Leier, CV, Shah, MR, Miller, LW, Russell, SD, Young, JB, Califf, RM & Nohria, A 2008, 'Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial.', Circulation. Heart failure, vol. 1, no. 3, pp. 170-177. https://doi.org/10.1161/CIRCHEARTFAILURE.108.769778
Drazner, Mark H. ; Hellkamp, Anne S. ; Leier, Carl V. ; Shah, Monica R. ; Miller, Leslie W. ; Russell, Stuart D. ; Young, James B. ; Califf, Robert M. ; Nohria, Anju. / Value of clinician assessment of hemodynamics in advanced heart failure : the ESCAPE trial. In: Circulation. Heart failure. 2008 ; Vol. 1, No. 3. pp. 170-177.
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AU - Drazner, Mark H.

AU - Hellkamp, Anne S.

AU - Leier, Carl V.

AU - Shah, Monica R.

AU - Miller, Leslie W.

AU - Russell, Stuart D.

AU - Young, James B.

AU - Califf, Robert M.

AU - Nohria, Anju

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N2 - BACKGROUND: We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure (HF). The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps due to lack of evidence for utility. METHODS AND RESULTS: We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the ESCAPE trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure (RAP) was <8 mm Hg in 82% of patients with RAP estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated RAP > or =12 mm Hg (odds ratio [OR] 4.6; P<0.001) and orthopnea > or =2 pillows (OR 3.6; P<0.05) were associated with pulmonary capillary wedge pressure (PCWP) > or =30 mm Hg. Estimated cardiac index did not reliably reflect measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 vs. 2.0 L/min/m(2); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization. CONCLUSIONS: In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.

AB - BACKGROUND: We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure (HF). The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps due to lack of evidence for utility. METHODS AND RESULTS: We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the ESCAPE trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure (RAP) was <8 mm Hg in 82% of patients with RAP estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated RAP > or =12 mm Hg (odds ratio [OR] 4.6; P<0.001) and orthopnea > or =2 pillows (OR 3.6; P<0.05) were associated with pulmonary capillary wedge pressure (PCWP) > or =30 mm Hg. Estimated cardiac index did not reliably reflect measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 vs. 2.0 L/min/m(2); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization. CONCLUSIONS: In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.

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