Guiding heart failure care by invasive hemodynamic measurements: Possible or useful?

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The quest to discover effective methodologies to monitor the course of disease and response to therapeutic agents in patients with chronic heart failure continues. The relentless progression of underlying left ventricular dysfunction and periodic, severe symptomatic decompensation often requiring hospitalization remain essential features of the heart failure syndrome despite significant therapeutic advances. Clinical trials of specific therapeutic agents have shown efficacy in large groups of patients. But outcome, even with the most effective agents, is recognized to be heterogeneous for largely unexplained reasons. The idea that treatment of individual patients with heart failure could be guided by serial measurements of surrogate end points for mortality and morbidity remains attractive to clinicians. Several assumptions underlie the concept that sequential physiologic measurements such as hemodynamics can be used to guide therapy: (1) measurements indicative of clinical response during heart failure can be ascertained, albeit with varying degrees of difficulty; (2) serial determinations of these measurements, such as left ventricular dysfunction, neurohormonal activation, and central hemodynamics, will predict clinical responses to general measures and pharmacologic therapy; (3) these measurements are not sufficiently risky, expensive, or cumbersome to preclude their being obtained as a part of routine clinical practice; (4) these measurements are sufficiently reproducible to provide the basis for making therapeutic changes in individual patients; (5) continuous measurements rather than serial snapshots of, for example, hemodynamics are likely best; (6) adjustment of currently available treatment strategies will favorably effect the measures that are monitored; (7) the frequency of therapeutic adjustments and subsequent follow-up study prompted by serial measurements is feasible for most patients; and (8) monitoring physiologic aspects of the disease process will provide more benefit than expending similar resources on changes in the process of delivery of care, ie, measurements of right heart hemodynamics with medication adjustment versus patient management via a heart failure program. Magalski et al in this issue of Journal of Cardiac Failure describe one strategy for monitoring the course of chronic heart failure that begins early work to address some of these issues.