Kussmaul Physiology in Patients with Heart Failure
Background—A paradoxical inspiratory rise in right atrial pressure (RAp, in contrast to the normal fall during inspiration), Kussmaul's sign, has been described in CHF. However, the clinical and hemodynamic characteristics, and clinical outcomes of patients with CHF and Kussmaul physiology have not been studied.
Methods and Results—This is a single-centre study of consecutive ambulant patients with CHF (NYHA class III/IV) referred for assessment for heart transplantation between November 2011 and April 2013. Kussmaul physiology was defined as inspiratory rise in right atrial pressure during right heart catheterization. Clinical, biochemical, echocardiographic and haemodynamic correlates were studied and outcomes assessed in patients with or without Kusmmaul physiology after a mean follow up of 379 ± 227 days. Ninety ambulant patients (Age 53±12 years, 86% Male) with CHF were studied. Kussmaul physiology was demonstrated in 39 (43%) of patients and it was associated with higher pulmonary pressures and lower cardiac index and pulmonary capacitance (all P<0.05). Patients with Kussmaul physiology were more likely to be treated with higher doses of diuretics while higher filling pressures, NTproBNP levels and hyponatraemia reflected greater neurohormonal activation. Echocardiography revealed greater left and right ventricular dimensions/volumes, restrictive transmitral filling pattern and lower left ventricular EF and lower tricuspid annular plane systolic excursion. Peak VO2 were low and comparable in both groups, but ventilation slope were higher in patients with Kussmaul physiology patients who also had a higher incidence of post-transplant right ventricular failure and overall mortality (p<0.05).
Conclusions—Kussmaul physiology is common in patients with CHF referred for heart transplantation and is associated with adverse cardiopulmonary hemodynamics. As a result of the latter, Kussmaul physiology is associated with poorer clinical outcomes. Kussmaul physiology may be useful during assessment of right heat function and pulmonary pressures prior to transplantation.
- Received May 30, 2013.
- Accepted February 28, 2014.