"To improve clinical outcomes, we must develop and implement algorithms that evaluate PAC data in a comprehensive manner inclusive of assessing right and left ventricular function, cardiac-filling pressures, and both systemic and pulmonary vascular resistance," Dr. Navin K. Kapur of Tufts Medical Center, in Boston, told Reuters Health by email. "These data can guide clinical decision making for our most critically ill patients."
PAC monitoring allows clinicians to assess the relative contributions of right and left ventricular failure to guide medical therapy. Several studies have shown no benefit from PAC-guided treatment in patients with decompensated heart failure, but these studies typically excluded patients with cardiogenic shock.
Dr. Kapur and colleagues used data from 1,414 patients with cardiogenic shock included in the Cardiogenic Shock Working Group registry to investigate the association between the use of PAC prior to initiation of mechanical circulatory support (MCS) and clinical outcomes.
Of these patients, 598 had complete hemodynamic assessments, 556 had incomplete assessments, and 260 had no PAC prior to MCS initiation.
Most study patients (53.6%) were in Society for Cardiovascular Angiography and Interventions (SCAI) Stage D, 18.6% were in Stage C, and 15% were in stage E.
As expected, mortality rates increased with worsening SCAI stage, from 11% in Stage C to 33% in Stage D and 55 % in Stage E.
In-hospital mortality differed significantly among PAC groups within the overall cohort and within each SCAI Stage and was lowest in the group that had complete PAC hemodynamic assessment, the researchers report in JACC: Heart Failure.
After adjustment for other factors, having no PAC assessment was associated with 57% greater odds of mortality and incomplete PAC assessment was associated with 71% greater odds of mortality, compared with complete PAC assessment.
Hemodynamic parameters associated with higher in-hospital mortality included decreased mean arterial pressure, increased right atrial pressure, and elevated heart rate. Pulmonary capillary wedge pressure, cardiac power output and cardiac index, on the other hand, did not appear to affect mortality consistently.
"If one uses a PAC, our data supports that complete data acquisition should be the standard of care for cardiogenic shock and may improve clinical outcomes by providing a more comprehensive assessment of hemodynamics," Dr. Kapur said.
Coauthor Dr. Manreet Kanwar of the Cardiovascular Institute at Allegheny Health Network, in Pittsburgh, Pennsylvania, told Reuters Health by email, "There is a school of thought that monitoring vital signs aided by physical examination and labs should be (enough) to manage these patients in the ICU. Although these may be adequate in the vast majority of hospitalized patients with heart failure, patients in cardiogenic shock are critically ill, with high associated mortality. Having timely, complete, and ongoing data as provided by PAC catheters can be critical in preventing the downward spiral in these patients, as was shown in our data."
Dr. James C. Fang of the University of Utah, in Salt Lake City, who coauthored a linked editorial, told Reuters Health by email, "Consider placing a PAC if a patient is not responding to shock therapy and before escalation of therapy to mechanical circulatory support."
"This data is supportive but not definitive; its use should be strongly considered in the appropriate scenarios," he said. "We await prospective studies that incorporate the use of the PAC for decision making in this high-risk group of patients."
SOURCE: https://bit.ly/3oz112z and https://bit.ly/37Q5g3Q JACC: Heart Failure, November 2020
By Will Boggs MD
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