Evaluation and Management of Patients with Acute Decompensated Heart Failure

Hemodynamic Monitoring

Recommendations

12.21

The routine use of invasive hemodynamic monitoring in patients with ADHF is not recommended. (Strength of Evidence = A)

12.22

Invasive hemodynamic monitoring should be considered in a patient:

  • who is refractory to initial therapy,
  • whose volume status and cardiac filling pressures are unclear,
  • who has clinically significant hypotension (typically SBP < 80 mm Hg) or worsening renal function during therapy, or
  • who is being considered for cardiac transplant and needs assessment of degree and reversibility of pulmonary hypertension, or
  • in whom documentation of an adequate hemodynamic response to the inotropic agent is necessary when chronic outpatient infusion is being considered. (Strength of Evidence = C)

Background

Treating symptoms and improving the hemodynamic profile of patients admitted with HF generally can be guided by skilled clinical assessment and laboratory evaluation. Direct hemodynamic monitoring by right heart catheterization has been advocated in the management of hospitalized patients with advanced HF to (1) guide therapy by permitting direct tracking of filling pressures and systemic vascular resistance until certain specific hemodynamic goals are reached and (2) assist in understanding volume status and tissue perfusion by direct determination of the extent and type of hemodynamic abnormalities present.139

The first concept, that treatment to a specific hemodynamic goal through the use of invasive hemodynamic monitoring may be of value in patients admitted with advanced HF, has been evaluated recently in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial.140 Hemodynamically guided therapy did not increase the number of days alive and out of hospital over the course of 6 months compared with standard management alone.141

Given the neutral results of ESCAPE, it is reasonable to ask whether or not there are patients admitted with ADHF who still need invasive hemodynamic monitoring. Patients with a clear clinical need for right heart catheterization were excluded from ESCAPE. Examples would include patients with cardiogenic shock. Uncertainty concerning the hemodynamic state of individual patients following careful clinical evaluation and initial therapy remains a reasonable indication for direct determination of hemodynamics. Invasive monitoring may benefit patients who are hypotensive, fail to respond to diuretic therapy, or have worsening renal function but unknown filling pressures and cardiac output. The need for invasive hemodynamics often becomes apparent as treatment progresses.

Clinical estimation or measurement of right atrial pressure usually correlates with left-sided filling pressures both at a single time point and during changes induced by medications. However, pulmonary disease or disproportionate right HF may alter this relationship. Right heart catheterization can assess LV filling pressures as long as accurate PCWP tracings can be obtained and there is no significant stenosis of the pulmonary veins or mitral valve. Complications associated with use of intra-cardiac catheters include ventricular arrhythmias and line-related infection. Incorrect interpretation of hemodynamic data or overtreatment based on data may also lead to adverse outcomes.142,143