Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure.
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.
Ritzema
Jay
J
University of Otago, Christchurch, New Zealand.
Troughton
Richard
R
Melton
Iain
I
Crozier
Ian
I
Doughty
Robert
R
Krum
Henry
H
Walton
Anthony
A
Adamson
Philip
P
Kar
Saibal
S
Shah
Prediman K
PK
Richards
Mark
M
Eigler
Neal L
NL
Whiting
James S
JS
Haas
Garrie J
GJ
Heywood
J Thomas
JT
Frampton
Christopher M
CM
Abraham
William T
WT
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
D000319:Adrenergic beta-Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D049994:Sodium Potassium Chloride Symporter Inhibitors