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


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.
Drazner
Mark H
MH
University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA. mark.drazner@utsouthwestern.edu
Hellkamp
Anne S
AS
Leier
Carl V
CV
Shah
Monica R
MR
Miller
Leslie W
LW
Russell
Stuart D
SD
Young
James B
JB
Califf
Robert M
RM
Nohria
Anju
A
D000368:Aged; D006328:Cardiac Catheterization / Q000379:methods*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology*; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011669:Pulmonary Wedge Pressure / Q000502:physiology; D012372:ROC Curve; D013318:Stroke Volume / Q000502:physiology; D016277:Ventricular Function, Left / Q000502:physiology
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