Physician-Directed Patient Self-Management of Left Atrial Pressure in Advanced Chronic Heart Failure

• Published in: Circulation (New York, N.Y.) N.Y.), 2010-03, Vol.121 (9), p.1086-1095
• Main Authors: RITZEMA, Jay, TROUGHTON, Richard, RICHARDS, Mark, EIGLER, Neal L, WHITING, James S, HAAS, Garrie J, HEYWOOD, J. Thomas, FRAMPTON, Christopher M, ABRAHAM, William T, MELTON, Lain, CROZIER, Ian, DOUGHTY, Robert, KRUM, Henry, WALTON, Anthony, ADAMSON, Philip, KAR, Saibal, SHAH, Prediman K
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - administration & dosage; Adrenergic beta-Antagonists - therapeutic use; Aged; Aged, 80 and over; Angiotensin II Type 1 Receptor Blockers - administration & dosage; Angiotensin II Type 1 Receptor Blockers - therapeutic use; Angiotensin-Converting Enzyme Inhibitors - administration & dosage; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Biological and medical sciences; Blood and lymphatic vessels; Blood Pressure Monitoring, Ambulatory - instrumentation; Blood Pressure Monitoring, Ambulatory - methods; Cardiology. Vascular system; Cardiovascular system; Combined Modality Therapy; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Double-Blind Method; Electrodes, Implanted; Equipment Design; Female; Heart Atria; Heart Failure - drug therapy; Heart Failure - mortality; Heart Failure - physiopathology; Heart Failure - therapy; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Medical sciences; Middle Aged; Pacemaker, Artificial; Pharmacology. Drug treatments; Prospective Studies; Self Care; Sodium Potassium Chloride Symporter Inhibitors - administration & dosage; Sodium Potassium Chloride Symporter Inhibitors - therapeutic use; Vasodilator agents. Cerebral vasodilators
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/circulationaha.108.800490

Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. We conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure. Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16 [95% confidence interval 0.04 to 0.68], P=0.012). Mean daily left atrial pressure fell from 17.6 mm Hg (95% confidence interval 15.8 to 19.4 mm Hg) in the first 3 months to 14.8 mm Hg (95% confidence interval 13.0 to 16.6 mm Hg; P=0.003) during pressure-guided therapy. The frequency of elevated readings (>25 mm Hg) was reduced by 67% (P