Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial

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.

Keywords: heart failure; hemodynamics; history and physical examination.

Figure 1

Number of patients stratified by their estimated RAP by H&P examination (vertically) and their measured RAP by right heart catheterization (horizontally).

Figure 2

Receiver operating characteristic curves for hemodynamic parameters estimated by the H&P examination or BNP as compared with invasively-measured values. Depicted curves are for estimated vs. measured RAP (A), estimated vs. measured PCWP (B), and BNP vs. measured PCWP (C). H&P examination estimates were in categories of: RAP <8, 8–12, 13–16, >16 mm Hg; PCWP <12, 12–22, 23–30, >30 mm Hg. BNP, measured by the Shinogi assay, was in categories of 100, 400, 1000, and 5000 pg/mL.

Figure 2

Receiver operating characteristic curves for hemodynamic parameters estimated by the H&P examination or BNP as compared with invasively-measured values. Depicted curves are for estimated vs. measured RAP (A), estimated vs. measured PCWP (B), and BNP vs. measured PCWP (C). H&P examination estimates were in categories of: RAP <8, 8–12, 13–16, >16 mm Hg; PCWP <12, 12–22, 23–30, >30 mm Hg. BNP, measured by the Shinogi assay, was in categories of 100, 400, 1000, and 5000 pg/mL.

Figure 2

Receiver operating characteristic curves for hemodynamic parameters estimated by the H&P examination or BNP as compared with invasively-measured values. Depicted curves are for estimated vs. measured RAP (A), estimated vs. measured PCWP (B), and BNP vs. measured PCWP (C). H&P examination estimates were in categories of: RAP <8, 8–12, 13–16, >16 mm Hg; PCWP <12, 12–22, 23–30, >30 mm Hg. BNP, measured by the Shinogi assay, was in categories of 100, 400, 1000, and 5000 pg/mL.