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Original Articles

Value of Clinician Assessment of Hemodynamics in Advanced Heart Failure

The ESCAPE Trial

Mark H. Drazner, MD, MSc; Anne S. Hellkamp, MS; Carl V. Leier, MD; Monica R. Shah, MD, MHS, MSJ; Leslie W. Miller, MD; Stuart D. Russell, MD; James B. Young, MD; Robert M. Califf, MD and Anju Nohria, MD

From the University of Texas Southwestern Medical Center (M.H.D.), Dallas ; Duke Clinical Research Institute, Duke University Medical Center (A.S.H., R.M.C.), Durham, NC ; The Ohio State University Medical Center (C.V.L.), Columbus ; Washington Hospital Center (M.R.S.), Washington, DC; Brigham and Women’s Hospital (A.N.), Boston, Mass; Washington Hospital Center and Georgetown University Hospital (L.W.M.), Washington, DC; Johns Hopkins Hospital (S.D.R.), Baltimore, Md; and Cleveland Clinic Foundation (J.B.Y.), Ohio.

Correspondence to Mark H. Drazner, MD, MSc, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047. E-mail mark.drazner{at}utsouthwestern.edu

Received December 6, 2007; accepted July 23, 2008.

Background— We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure. The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps because of the lack of evidence for utility.

Methods and Results— We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure was <8 mm Hg in 82% of patients with right atrial pressure estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated right atrial pressure 12 mm Hg (odds ratio, 4.6; P<0.001) and orthopnea 2 pillows (odds ratio, 3.6; P<0.05) were associated with pulmonary capillary wedge pressure 30 mm Hg. Estimated cardiac index did not reliably reflect the measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 versus 2.0 L/(min·m²); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization.

Conclusions— In advanced heart failure, the presence of orthopnea and increased jugular venous pressure is useful to detect increased pulmonary capillary wedge pressure, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.

Key Words: diagnosis • heart failure • hemodynamics • history and physical examination

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CLINICAL PERSPECTIVE

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