Pulmonary Artery Pressure-Guided Heart Failure Management Reduces Hospitalizations in Patients With Chronic Kidney Disease

Abstract

Background: Hemodynamic-guided heart failure management is a superior strategy to prevent decompensation leading to hospitalization compared with traditional clinical methods. It remains unstudied if hemodynamic-guided care is effective across severities of comorbid renal insufficiency or if this strategy impacts renal function over time.

Methods: In the CardioMEMS US PAS (Post-Approval Study), heart failure hospitalizations were compared from 1 year before and after pulmonary artery sensor implantation in 1200 patients with New York Heart Association class III symptoms and a previous hospitalization. Hospitalization rates were evaluated in all patients grouped into baseline estimated glomerular filtration rate (eGFR) quartiles. Chronic kidney disease progression was evaluated in patients with renal function follow-up data (n=911).

Results: Patients with stage 2 or greater chronic kidney disease at baseline exceeded 80%. Heart failure hospitalization risk was lower in all eGFR quartiles ranging from a hazard ratio of 0.35 (0.27-0.46; P<0.0001) in patients with eGFR >65 mL/min per 1.73 m² to 0.53 (0.45-0.62; P<0.0001) in patients with eGFR ≤37 mL/min per 1.73 m². Renal function was preserved or improved in most patients. Survival was different between quartiles and lower in quartiles with more advanced chronic kidney disease.

Conclusions: Hemodynamic-guided heart failure management using remotely obtained pulmonary artery pressures is associated with lower hospitalization rates and general preservation of renal function in all eGFR quartiles or chronic kidney disease stages.

Keywords: diuretics; heart failure; hemodynamics; hospitalization; renal insufficiency.

Figure 1.

Composition of cohorts used to examine heart failure outcomes and renal progression hypotheses.

Figure 2.

Outcomes across eGFR quartiles. A, Heart failure hospitalization (HFH) rates 12 months before implantation compared with 12 months after implantation based on estimated glomerular filtration rate (eGFR) quartiles (n=1200). Change in pulmonary artery (PA) pressures over time using an area under the curve analysis, based on eGFR quartiles in the entire population of 1200 enrolled patients (B). C, Depicts Kaplan-Meier survival analysis of all patients stratified by eGFR quartile at baseline. Kaplan-Meier survival expressed as % (95% CI). EPPY indicates events per patient year. *Includes all Clinical Events Committee (CEC) adjudicated heart failure hospitalizations with an admission date on the date of implant and through 390 days prior to the date of implant. †Includes all CEC adjudicated heart failure hospitalizations with an admission date after the implant procedure discharge date through 390 days after the date of implant. ‡Hospitalization rate is an annualized rate estimated from the Andersen-Gill model. {95% CI on annualized hospitalization rate from the Andersen-Gill model. ‖Hazard ratio, 95% CI, and P value estimated from the Andersen-Gill model with robust sandwich estimates.

Figure 3.

Chronic kidney disease (CKD) stage change over the 12-month follow-up period in patients based on their baseline CKD stage. Improvement was defined as a change of at least on stage lower than baseline and worsened was defined as a change that was at least 1 stage higher than baseline.