PA pulse pressure survival curves

Decreased PA Pulse Pressure After PA Catheter Optimization

May 22, 2017

Key Takeaways

  • There are few studies that demonstrate the full impact of pulmonary arterial proportional pressure (PAPP) on advanced heart failure (HF) outcomes.
  • It has been theorized that increases in PAPP would correlate with improved clinical outcomes in patients with advanced HF.
  • Researchers evaluated the PAPP of a subset of patients in the ESCAPE trial who had received placement of a pulmonary artery catheter (PAC).
  • A lower PAPP score was consistently associated with worse hemodynamics and increased clinical events at 6 months.
  • PAPP may be an important risk stratification tool for HF patients, assisting in the prediction of mortality, LVAD transplant, and hospitalization.

The functional status of the right ventricle represents an important independent predictor for disease course in patients with advanced heart failure (HF). Pulmonary arterial proportional pulse pressure (PAPP), defined as [PA systolic pressure – PA diastolic pressure]/PA systolic pressure, on advanced HF outcomes has also been suggested as a risk predictor, yet this remains little explored.

An analysis published in the Journal of Cardiac Failure examined the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial to determine the association between the index PAPP and clinical outcomes of advanced HF.1 Researchers hypothesized that using a pulmonary artery catheter (PAC) to increase PAPP following hemodynamic improvement would correlate with more optimal clinical outcomes for HF patients.

The ESCAPE trial studied the efficacy of hemodynamically guided therapy in acute decompensated HF patients in 26 centers throughout a 3-year period (2000-2003). A 1:1 PAC to guided therapy by clinical assessment compared with a guided therapy clinical assessment without a PAC was used in the study’s design.

This study analyzed patients (n=433) from the ESCAPE database who were randomly assigned to PAC placement and had their complete invasive hemodynamic data recorded at the end of guided therapy. Researchers also examined the minimum threshold value for nonoptimal PAPP (NPAPP) and optimal PAPP (OPAPP).

Only 175 out of the original 433 patients were included in this cohort, as the discharge hemodynamic data was available for this population only. Mortality in the OPAPP group was lower when compared with the NPAPP patient group.

Figure 1. Kaplan-Meier Survival Curvesa
Kaplan-Meier Survival Curves
aData from Mazimba S, Kennedy JL, Zhuo D, et al1

A PAPP of ≤0.50 recorded at final hemodynamic assessment was associated with significantly worse clinical outcomes for advanced HF patients even after researchers adjusted for pulmonary capillary wedge pressure. These outcomes included higher incidences of death, left ventricular assist device (LVAD) insertion, transplantation, and rehospitalization.

The use of PAPP as a tool for risk stratification may be an easy independent metric for improving care for patients with HF. Additionally, researchers of this study believe PAPP can be a practical hemodynamic target during HF therapy and assist in stratifying risk for patients receiving implantable pressure monitoring devices.

Reference:

  1. Mazimba S, Kennedy JL, Zhuo D, et al. Decreased Pulmonary Arterial Proportional Pulse Pressure After Pulmonary Artery Catheter Optimization for Advanced Heart Failure Is Associated With Adverse Clinical Outcomes. J Card Fail. 2016;22(12):954-961.

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