Back to the Future or Nostalgia? Heart Failure and Right-Sided Pressures
I will preface this missive with some facts. Summer 2016 will be the 42-year anniversary of my medical school graduation. In the dark ages of my residency, echocardiography was a novelty and could not be ordered by residents unless we predicted a significant finding. In that “backward” environment, I got pretty good at evaluating jugular venous pressures. In fact, when my predictions went awry, my professors brought my misadventures to my attention less than diplomatically. Tachycardia in the resident, not the patient, was the consequence.
Now let’s review some staggering facts about heart failure, examination findings, and novel cardiac evaluation techniques. Worldwide, 26 million people are affected by heart failure.1 In the United States, 1 million people each year are admitted to a hospital with heart failure.1 How about estimating the dollars and cents of this critical heart equation? It has been predicted that costs for heart failure in the United States in 2030 will reach $70 billion!1
What can we do to make things better?
This month’s Top Paper takes what appears to be a promising approach.1 The CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial proposes a new category of monitoring for heart failure patients—a hemodynamic evaluation by a technologic innovation, an implanted pulmonary artery (PA) sensor. Having access to elevated PA pressure values can guide therapy and improve diuresis before patients require admission for worsening heart failure symptoms.
In this study, the patients with heart failure cared for by physicians who were apprised of PA pressure readings required 33% less admissions than did the patients whose physicians who did not have access to the PA sensor values.
But what if the study design were revised to some degree? Would the 33% difference in admission rates be as striking if less-expensive monitoring had been provided, either with a careful jugular examination (by someone good at this technique) or even with a portable echocardiography device? I do not know what an implanted PA sensor costs, but it has to be more costly than an examination or a bedside echo. I am not implying that my examination skills are superior to a PA sensor or an echocardiogram, but in most practice situations, immediate access to technology of this sophistication is not likely.
A cardiologist friend who is as “aged” as I am says that his younger partners laugh at his careful estimation of PA pressure on examination. Relying on a good examination and using expensive technology are not mutually exclusive categories (I think it was Aristotle who came up with that logic). When a patient has elevated jugular pressure, and there is no access to a PA sensor or portable echo machine, increasing diuretic doses is probably a good idea. Since you and I will probably not have immediate access to PA sensors, we have to use what we have with us.
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.
- Abraham WT, Stevenson LW, Bourge RC, Lindenfeld JA, Bauman JG, Adamson PB; CHAMPION Trial Study Group. Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial. Lancet. 2016;387 (10017):453-461.