title: Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure.
abstract: BACKGROUND
  Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. We conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure.
  
  
  RESULTS
  Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16 [95% confidence interval 0.04 to 0.68], P=0.012). Mean daily left atrial pressure fell from 17.6 mm Hg (95% confidence interval 15.8 to 19.4 mm Hg) in the first 3 months to 14.8 mm Hg (95% confidence interval 13.0 to 16.6 mm Hg; P=0.003) during pressure-guided therapy. The frequency of elevated readings (>25 mm Hg) was reduced by 67% (P<0.001). There were improvements in New York Heart Association class (-0.7+/-0.8, P<0.001) and left ventricular ejection fraction (7+/-10%, P<0.001). Doses of angiotensin-converting enzyme/angiotensin-receptor blockers and beta-blockers were uptitrated by 37% (P<0.001) and 40% (P<0.001), respectively, whereas doses of loop diuretics fell by 27% (P=0.15).
  
  
  CONCLUSIONS
  Physician-directed patient self-management of left atrial pressure has the potential to improve hemodynamics, symptoms, and outcomes in advanced heart failure. Clinical Trial Registration Information- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00547729.
authors.affiliation: University of Otago, Christchurch, New Zealand.
authors.forename: Jay
authors.initials: J
authors.lastname: Ritzema
authors.forename: Richard
authors.initials: R
authors.lastname: Troughton
authors.forename: Iain
authors.initials: I
authors.lastname: Melton
authors.forename: Ian
authors.initials: I
authors.lastname: Crozier
authors.forename: Robert
authors.initials: R
authors.lastname: Doughty
authors.forename: Henry
authors.initials: H
authors.lastname: Krum
authors.forename: Anthony
authors.initials: A
authors.lastname: Walton
authors.forename: Philip
authors.initials: P
authors.lastname: Adamson
authors.forename: Saibal
authors.initials: S
authors.lastname: Kar
authors.forename: Prediman K
authors.initials: PK
authors.lastname: Shah
authors.forename: Mark
authors.initials: M
authors.lastname: Richards
authors.forename: Neal L
authors.initials: NL
authors.lastname: Eigler
authors.forename: James S
authors.initials: JS
authors.lastname: Whiting
authors.forename: Garrie J
authors.initials: GJ
authors.lastname: Haas
authors.forename: J Thomas
authors.initials: JT
authors.lastname: Heywood
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Frampton
authors.forename: William T
authors.initials: WT
authors.lastname: Abraham
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D018660:Blood Pressure Monitoring, Ambulatory / Q000295:instrumentation / Q000379:methods; D003131:Combined Modality Therapy; D004311:Double-Blind Method; D004567:Electrodes, Implanted; D004867:Equipment Design; D005260:Female; D006325:Heart Atria; D006333:Heart Failure / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011446:Prospective Studies; D012648:Self Care; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D000319:Adrenergic beta-Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D049994:Sodium Potassium Chloride Symporter Inhibitors