The best way to measure congetion

The Best Way To Measure Congestion

What site and what intervention?

Most days for patients are not clinic days.

The right congestion signal from home is early, actionable, and responsive

Therapy guided by home pressures > therapy guided by other changes

Pressures respond to both diuretics and vasodilators.

Pressure-guided strategy also addresses HF with preserved EF

Any strategy that averts re-congestion should decrease HF progression to cardio-renal

impairment and right heart failure.

Do we aim for optimal pressures or wait until something gets worse?

Confidential C 2

ACC/AHA Guidelines for HF Management

3. Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea (Level of Evidence: B)

6.1. Clinical Evaluation

Class I Recommendation

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines - 2013

Assessment of Congestion:

Where and With What Response?

Preventing HF Re-Admissions: The “Best” Care is Not Good Enough

National HF readmission rates over 20% at 1 month

Pts called at 1-2 days, seen at 7-14 days

Re-education regarding Na restriction + fluid limit

Monitor daily weights: 2 pound increase – 2 Xe diuretic dose

(or “metolazone booster”) until resolved

Phone number to call for symptoms or weight gain

No

orthodema

52% Low-grade

orthodema

32%

High-

grade

orthodema

16%

Discharge

a

No

orthodema

35%

Low-grade

orthodema

27%

High-

grade

orthodema

38%

60-day Follow up

De-congestion and Re-Congestion After Hospitalization

Lala, Mentz, Vader for HFAN

From NHLBI Heart Failure Network Trials

Under revision for Circ HF

Pressure Rises Early In Decompensation

Same Course Tracked with Different Devices

Adamson P, et al. European Heart Journal (2012) 33 (Abstract Supplement), 650-651.

6

Bourge et al, from COMPASS trial

2009, Chronicle device in RV

RV Diastolic Pressure

Adamson et al, 2012

CARDIOMEMS device in PA

The Gathering Storm

Why are we missing it?

Assessment of Congestion:

Where and With What Response?

???

Most Days of Heart Failure Management

Are Blind

HF Clinic

Device Clinic

Home


What site for what intervention?









Response and Re-assessment

Right Signal

Right Action

Monitoring To Avert Decompensation

Need for Iteration and Simplicity

Listening For Reports of Edema and Weight Changes:

Many patients never get edema

despite severe volume overload,

particularly in patients < 65 yrs

Edema usually indicates > 4 pounds of

fluid retention.

Weight often does not change as fluid

increases, if appetite decreases.

Weight may increase over longer

period when patients eat better.

< 2 lbs

3 to 5

6 to 10

> 10

Patients admitted with HF:

Most had < 2 lbs weight gain

Chaudry, Wang, Concato, Gill, Krumholz

Circulation 2007: 116: 1549-54

Most HF Hospitalizations

Were Not Preceded by Obvious Weight Gain

Listening To More Weights and Symptoms

Did Not Decrease Admissions

Chaudry, Mettera, Curtis, Spertus, Herrin, Lin,

Phillips, Hodson, Cooper, Krumholz. NEJM 2010:363:2301-9

With Good HF Management, Increases in Pulmonary Artery Pressures

(But Not Body Weight) Precede Hospitalization for Heart Failure

lbs mmHg

Body Weight RV Diastolic Pressure

Data from the COMPASS trial Bourge et al

I

For the right signal, Wisdom it is not To weight.


What site for what intervention?




Pressure-guided therapy includes both diuretics and vasodilators.





Medication Changes During 6 Months:

Blind Vs Monitored

Blind Therapy Monitored Therapy

Total med changes 1061 2517 p<0.0001

Diuretic changes 585 1547 p< 0.0001

per pt/month 0.3 0.8

Nitrate dose change

(mean/day)

+ 4 mg + 18 mg p< 0.04

Hydralazine change +22 mg + 33 mg NS

ACEI change 0 mg + 4 mg p< 0.01

Beta blocker +0.6 +3.4 mg p<0.05

Costanzo, HFSA 2011

Increasing Benefit to Decrease HF Hospitalization

Annualized 33% decrease

In hospitalizations

NNT = 4 to prevent 1 hosp

49.8 50.2

75.4

24.6

0

10

20

30

40

50

60

70

80

% o

f M

ed

icati

on

s C

han

ges

w-PAP Increases w-PAP Decreases

Medications Adjustments

in Response to w-PAP Changes

Diuretics

Other Medications

629 633

107 35

Diuretics and vasodilators

used when pressures high

Diuretics changed when

pressures decreased.

Costanzo et al, HFSA 2011


Where and for what intervention?









Heart Failure Events Develop Slowly Regardless

of LVEF

25

27

29

31

33

35

37

-70 -60 -50 -40 -30 -20 -10 0 10 20

Time (days)

ePAD

(mmH

g)

Heart Failure

Related Event

Heart failure low EF

Heart failure preserved EF

21 days

Zile et al

COMPASS Investigators

Circulation 2008

Benefit of Pressure-Guided Strategy

in Champion Trial

Extends to HF with Preserved EF

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Reduced EF Preserved EF

Control Hosp

Champion Hosp

Hazard Ratio

Adamson P et al, Circ Heart Failure, 2014

N=430 N=119

Rate of Hospitalzations

And Reduced Hazard Ratio

for Monitored Patients

DHF Patients

Mean ePAD Pressure through: first HF event (event patients), randomized follow-up (non-event patients)

Lo

g(H

az

ard

)

10 20 30 40 50

-2-1

01

2

2515

SHF Patients

Mean ePAD Pressure through: first HF event (event patients), randomized follow-up (non-event patients)

Log(

Haz

ard)

10 20 30 40 50

-3-2

-10

12

2515

HF with Preserved EF

HF with Low EF

Optimal daily

filling pressures for

HFpEF:

Not enough data

yet to know if

the curve is U-shaped

Circulation HF

2010

Likelihood

Of HF Events

Daily PAD pressures

Daily PAD pressures

mm

Congestion is Not Just a Symptom

Disease Progression

All the correlates of congestion are the strongest

predictors of mortality.

Congestion leads to hospitalizations which correlate

with higher mortality.

Congestion in the left heart leads to pulmonary

hypertension which loads the right ventricle.

High right atrial pressures are linked to the

cardiorenal syndrome.

Right heart failure is the major harbinger of

increasing morbidity and mortality in advanced heart

failure.

The Right Ventricle -

The Tipping Point

As pulmonary hypertension develops,

RV dysfunction begins to be detectable

when PAD pressures exceed 20 mm Hg.

Median Daily ePAD mmHg

Circ Heart Fail. 2010 Sep;3(5):580-7..

Probability of HF Event Related to

Estimated PA Diastolic Pressure Plateau

Risk of HF Event Related to Baseline PA Pressures –

CHAMPION

Impact of home PA pressure

monitoring

Baseline pressures

known for all patients

Costanzo et al

HFSA 2011

CHAMPION Trial:

All Secondary Efficacy Endpoints Met

Abraham WT, Adamson PB, Bourge RC, et al: Lancet 2011;377:658

Stage A. Diuretics Help Prevent Heart Failure from HTN

Not Just for Symptoms

0

0.2

0.4

0.6

0.8

1

Vs Placebo Vs ACEI Vs ARB Vs Bblockers

HF Risk All CVD Events

Psaty BM, Lumley T, Furberg CD,

Pahor M, Alderman MH, Weiss NH.

JAMA 2003: 289: 2534-44

“Low-dose diuretics are the most effective (+cost-effective) first-line therapy

for preventing the occurrence of cardiovascular morbidity and mortality.”

COMPASS Trial: Treatment for Increasing PA Pressures

Decreased Risk of HF Hospitalization

But Not Enough

HR = 0.64 [0.42 - 0.96], p=0.03

0 50 100 150 200

0.0

0.2

0.4

0.6

0.8

1.0

124 120 108 101 93 89 84 4

Number at Risk

132 119 110 91 87 80 77 3

Hemonitoring

CONTROL

Fre

edom

fro

m H

ospitaliz

ation

Days from Randomization

Hemodynamic monitoring

CONTROL

Home monitored

pressures

Better but not good enough?

Increasing Benefit to Decrease HF Hospitalization

Annualized 33% decrease

In hospitalizations

NNT = 4 to prevent 1 hosp

Treat the peaks

Lower the plateau

Level the valleys

Three Targets for Ambulatory Pressures

Symmetric Strategy Includes

Adjusting Diuretics Up AND Down

The “Right Dose” for Every Day

Ritzema et al

Circ 2010;121: 1086-95

Physician-Directed Patient Self-Management of LAP

in HOMEOSTASIS Trial

Guided Care Changes (6 mos)

Cp to Observation Period (3 mos)

Daily Diuretic Dose

27% From 151 to 109 mg

Diuretic Changes on 53% of days:

Higher on 29% of days

Lower on 24% of days

Neurohormonal Therapies To Modify

Disease:

ACEI/ARB Dose

37%

Beta blocker

Dose 40%

Response and Re-assessment

Right Signal

Right Action

Monitoring for Congestion:

Empower the Patient for Self-Management

Into the hands

of the patient

The

Cardio-Renal

Syndrome RA

RV Equally common with heart failure

Low EF and HF preserved EF

The major hemodynamic correlates

are tricuspid regurgitation and

high right atrial pressures.

The best way to measure congetion

Healthcare

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