Congestive heart failure invasive monitoring

Congestive Heart Failure Microchapters
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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Based upon the results of the ESCAPE trial, there is no benefit in clinical outcomes associated with the routine use of a pulmonary artery line in patients with decompensated CHF.

Supportive Trial Data

The ESCAPE trial (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness), was the first large, multicenter, randomized controlled trial that enrolled 433 patients across 26 sites, to determine the safety of pulmonary artery catheter (PAC) or Swan-Ganz catheter use to improve clinical outcomes in patients hospitalized with severe symptomatic and recurrent heart failure. Off the total 433 patients enrolled, 218 patients were randomized to clinical assessment alone (clinical arm) and the remaining 215 were randomized to both PAC and clinical assessment (PAC arm); with almost all patients being treated with loop diuretics (98%), ACE inhibitors (79%), beta-blockers (62%), and spironolactone (51%) and only a small percentage received inotropes (15%) and intravenous vasodilators (8%) at the time of randomization. At 6-month follow up, the primary endpoint achieved was identical and non-significant among both the arms with an overall mortality of 19%. Thus, the study concluded no benefit demonstrated with the use of PAC for the improvement of clinical outcomes in patients with advanced heart failure.

ACC/AHA Guidelines- Invasive Hemodynamic Monitoring Recommendation

Class I

"1. Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C) "

Class IIa

"1. Invasive hemodynamic monitoring can be useful for carefully selected patients with acute heart failure who have persistent symptoms despite empiric adjustment of standard therapies, and (Level of Evidence: C)

" a. Whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain,"

" b. Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy,"

" c. Whose renal function is worsening with therapy,"

" d. Who require parenteral vasoactive agents or"

" e. Who may need consideration for advanced device therapy or transplantation. "

Class III (No Benefit)

"1. Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended. (Level of Evidence: B) "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

References

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