Upswing Seen in Pulmonary Artery Catheter Use in Acute Heart Failure

Pulmonary artery catheterization in heart failure patients has unexpectedly grown more common in recent years, with no clear explanation for the trend, a new study shows.

About three-quarters of the cases in which invasive monitoring is used, in fact, have involved patients without cardiogenic shock or a need for mechanical ventilation, Gregg Fonarow, MD, of Ronald Reagan UCLA Medical Center (Los Angeles, CA), and colleagues report.

That is despite the fact that the most recent heart failure guidelines discourage routine use of invasive hemodynamic monitoring with a pulmonary artery catheter in the acute setting in normotensive patients who respond to diuretics and vasodilators due to a lack of benefit.

“These findings suggest an opportunity for improvement in quality of care and reduction in healthcare expenditures among patients hospitalized with acute heart failure,” Fonarow told TCTMD in an email. “Some strategies for improvement include greater education of physicians about current ACC/AHA guideline recommendations discouraging the use of pulmonary artery catheters in heart failure patients without cardiogenic shock or respiratory failure.”

He added that “consideration should be given for incorporation of clinical decision support tools in day-to-day care of heart failure patients to assist physicians with real-time guidance about the appropriateness of invasive monitoring.”

In the study, published online as a research letter in JAMA Internal Medicine this week, the investigators looked at data from the National Inpatient Sample on 2,492,284 adult patients hospitalized with a primary diagnosis of heart failure between 2001 and 2012. That translates to an estimated 11.9 million heart failure hospitalizations in the United States during the study period.

Overall, pulmonary artery catheterization was used in only 0.6% of hospitalizations. Most of those cases (74%) involved patients who did not have either cardiogenic shock or a need for mechanical ventilation. Among those who underwent such monitoring, there were reductions in mean age and rates of acute MI, cardiac arrest, and use of mechanical ventilation and increases in rates of cardiogenic shock and CAD over time.

The rate of pulmonary artery catheter use (per 1,000 hospitalizations) initially declined from 7.9 in 2001 to 4.9 in 2007 before rising back up to 7.9 in 2012. Similar patterns were observed in the subgroups of patients with cardiogenic shock (190 to 86 to 121) and those without either cardiogenic shock or a need for mechanical ventilation (5.6 to 4.2 to 6.5). In contrast, catheter use declined steadily over the study period in patients with a need for mechanical ventilation but no shock (50 to 10).

Discordance With Guidelines

The recommendation against routine use of pulmonary artery catheterization in the acute heart failure setting came following the 2005 publication of the ESCAPE trial, which showed that monitoring does not affect the number of days alive and out of the hospital in the first 6 months (primary endpoint), mortality, or the number of days hospitalized compared with clinical assessment alone.

“In the period leading up to the ESCAPE trial, there were a number of observational studies that suggested use of pulmonary artery catheters in patients hospitalized with heart failure was associated with increased mortality potentially as a result of higher use of inotropic agents,” Fonarow noted. “This growing body of evidence may have contributed to the decline observed in use in this period.”

He said it was “quite surprising” to see a rise in the use of pulmonary artery catheters in the period after publication of the trial results, adding that the reason remains unclear. In their paper, he and his colleagues say that “increasing use of advanced [heart failure] therapies and the preparatory hemodynamic evaluations and increasing prevalence of comorbidities such as pulmonary hypertension and chronic kidney disease that may prompt invasive assessment of volume status” might explain the increase.

“This finding highlights the discordance between guideline recommendations and current clinical practice regarding management of acute [heart failure],” he and his colleagues write in their paper.

Further research is needed to explore to what degree inappropriate use may be to blame for the growth of pulmonary artery catheter use, they say.

“These findings suggest that at least some of the pulmonary artery catheter use in hospitalized heart failure is inconsistent with current clinical trial evidence and current ACC/AHA guidelines,” Fonarow said. “However, in some of the cases there may have been indications for pulmonary artery catheter use that were not fully captured in this study.”

Source:
Pandey A, Khera R, Kumar N, et al. Use of pulmonary artery catheterization in US patients with heart failure, 2001-2012. JAMA Intern Med. 2015;Epub ahead of print.