Value of Clinician Assessment of Hemodynamics in Advanced Heart Failure

Abstract

Background— We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure. The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps because of the 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 Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure was <8 mm Hg in 82% of patients with right atrial pressure 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 right atrial pressure ≥12 mm Hg (odds ratio, 4.6; P <0.001) and orthopnea ≥2 pillows (odds ratio, 3.6; P <0.05) were associated with pulmonary capillary wedge pressure ≥30 mm Hg. Estimated cardiac index did not reliably reflect the measured cardiac index ( P =0.09), but “cold” versus “warm” profile was associated with lower median measured cardiac index (1.75 versus 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 heart failure, the presence of orthopnea and increased jugular venous pressure is useful to detect increased pulmonary capillary wedge pressure, 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.