Pulmonary Artery Catheterization Use And Mortality In Heart Failure Patients  

The current study is the first to show that the use of pulmonary artery catheterization (PAC) declined from 2005 to 2010 in both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) but has since increased from 2010 to 2014 in both HFrEF and HFpEF.

This is also the first study to demonstrate that there is a temporal decline in excess mortality associated with PAC use in both HFrEF and HFpEF.  

Why was this study done? 

Two randomized trials, ESCAPE and PAC-Man demonstrated no benefit of routine use of PAC in acute heart failure patients. Hence, current American College of Cardiology and American Heart Association guidelines for heart failure recommends against the use of routine invasive monitoring with PAC in normotensive HF patients. These guidelines recommend PAC use to guide therapy only in patients with respiratory distress or clinical evidence of impaired perfusion in whom volume status, adequacy, or excess of intra-cardiac filling pressures cannot be clinically ascertained.

Despite these recommendations, the use of PAC was reported to have increased in recent years. It was not known if the use had increased in both types of heart failure (HFrEF and HFpEF). Hence, we analyzed the trends in PAC use as well as associated mortality in HFrEF and HFpEF. 

How was this study conducted? 

We obtained data from the nation’s largest publicly-available database, the National Inpatient Sample (NIS). Data was obtained from 2005 to 2014. The NIS is developed by the Healthcare Cost and Utilization Project and sponsored by the Agency for Healthcare Research and Quality. We used the International Classification of Diseases, 9^th revision (ICD-9) diagnostic codes to identify heart failure hospitalizations as well as PAC use. Hospitalizations with acute systolic heart failure and acute diastolic heart failure were included. 

What were the major findings of this study? 

There was a decline in the use of PAC from 2005 to 2010 in both HFrEF and HFpEF. However, from 2010 to 2014, the use of PAC increased significantly in both HFrEF (7.9 in 2010 to 9.7 in 2014 per 1000 hospitalizations, P_trend <0.001) and HFpEF (5.5 in 2010 to 6.7 in 2014 per 1000 hospitalizations, P_trend <0.001).

Although adjusted in-hospital mortality remained high with PAC use in both HFrEF and HFpEF, the excess mortality associated with PAC use declined throughout the study period from 2005 to 2014 in both HFrEF and HFpEF. The length of stay and cost remain significantly higher in both HFrEF and HFpEF patients with PAC use. The increased use of PAC in heart failure patients in recent years can be attributed to increased use in teaching hospitals, academic centers, and large urban hospitals with advanced therapies for heart failure such as left ventricular assist device, extracorporeal membrane oxygenation, and transplantation. These centers either perform such therapies or evaluate the patients for eligibility of such therapies, both of which necessitates the use of PAC. The temporal decline in excess mortality related to PAC use over the years can be at least partly attributed to improvement in therapies over the last decade. 

Future perspective 

As heart failure therapy keeps advancing, PAC is an important adjunctive tool, the use of which has increased and will likely continue to rise. It can provide valuable information, which, when combined with novel therapies, can prove beneficial to patients with heart failure. 

These findings are described in the article Pulmonary artery catheterization use and mortality in hospitalizations with HFrEF and HFpEF: A nationally representative trend analysis from 2005 to 2014, recently published in the International Journal of Cardiology. This work was conducted by Rajkumar Doshi from the University of Nevada Reno School of Medicine, Hiten Patel from New York Medical College at St. Joseph’s Regional Medical Center, and Priyank Shah from the Medical College of Georgia (Southwest Clinical Campus)/Phoebe Putney Memorial Hospital.