Ambulatory Pulmonary Artery Pressure Monitoring Research Articles

Ambulatory Pulmonary Artery Pressure Monitoring Reduces Costs and Improves Outcomes in Symptomatic Heart Failure: A Single-Centre Canadian Experience

BackgroundPulmonary artery pressure (PAP) monitoring reduces heart failure (HF) hospitalizations (HFHs) and improves quality of life in New York Heart Association (NYHA) class III HF. We evaluated the impact of PAP monitoring on outcomes and health spending in a Canadian ambulatory HF cohort. MethodsTwenty NYHA III HF patients underwent wireless PAP implantation at Foothills Medical Centre, Calgary, Alberta. Baseline, and 3-, 6-, 9-, and 12-month assessments of laboratory parameters, hemodynamics, 6-minute walk text and Kansas City Cardiomyopathy Questionnaire scores were collected. Healthcare costs 1 year pre- and post-implantation were collected from administrative databases. ResultsMean age was 70.6 years; 45% were female. Results were as follows: an 88% reduction in emergency room visits (P = 0.0009); an 87% reduction in HFHs (P < 0.0003); a 29% reduction in heart function clinic visits (P = 0.033), and a 178% increase in nurse calls (P < 0.0002). Questionnaire and 6-minute walk test scores at baseline vs last follow-up were 45.4 vs 48.4 (P = 0.48) and 364.4 vs 402.8 m (P = 0.58), respectively. Mean PAP at baseline vs follow-up was 31.5 vs 24.8 mm Hg (P = 0.005). NYHA class improved by at least one class in 85% of patients. Mean measurable HF-related spending preimplantation was CAD$29,814 per patient per year and postimplantation was CAD$25,642 per patient per year (including device cost). ConclusionsPAP monitoring demonstrated reductions in HFHs, and emergency room and heart function clinic visits, with improvements in NYHA class. Although further economic evaluation is needed, these results support the use of PAP monitoring as an effective and cost-neutral tool in HF management in appropriately selected patients in a publicly funded healthcare system.

Reduction in 90 Day Readmission Rates with Ambulatory Pulmonary Artery Pressure Monitoring

<h3>Purpose</h3> In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association [NYHA] Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lowered in patients with ambulatory pulmonary artery pressure (PAP) monitoring guidance. All cause 30 day readmission rates were also lowered in subsequent analysis of this trial. In the era of bundle payments and value-based medicine, the effect of ambulatory hemodynamic monitoring on 90 day all cause readmission rates post HFH has not been explored. <h3>Methods</h3> We conducted a retrospective analysis across the Advocate-Aurora healthcare hospital network using patients undergoing PAP sensor implantation between October 1, 2015, and October 31, 2019. Heart transplant or ventricular assist device (VAD) prior to implant were excluded. Rates of total HFH, 30 day all cause readmission, and 90 day all cause readmission rates after an index HFH event were collected during 12 months before implantation and until heart transplant, VAD, death, or 12 months post implantation. <h3>Results</h3> Among 459 patients, there were 404 total HFHs (0.43 events / per patient / per 180 days) before, compared with 179 HFHs (0.18 events / per patient / per 180 days) after implantation (incidence rate ratio [IRR]: 0.48 (0.40 - 0.57), p < .0001). Compared to pre-implantation, there was a lower rate of 30 day all cause readmission rates (IRR: 0.55 (0.39 - 0.77), p = 0.0006) and 90 day all cause readmission rates post implantation (IRR: 0.45 (0.35 - 0.58), p < .0001). The effect of PAP sensor implant on 90 day all cause readmission incidence rates was consistent across multiple subgroups. (Figure 1) <h3>Conclusion</h3> In a contemporary practice setting across a large hospital network, ambulatory hemodynamic monitoring was associated with lower HFH rates, 30 day and 90 day all cause readmission rates. These benefits support the utility of ambulatory pulmonary pressure monitoring to improve HF management in the era of value based medicine.

The Benefits of Ambulatory Pulmonary Artery Pressure Monitoring in Patients with Heart Failure

Purpose CHAMPION trial showed a reduction in CHF hospitalizations with the utilization of the CardioMEMS device. We hope to expand on this trial by correlating pulmonary artery pressure to other variables of volume status, such as creatinine, pro-BNP, hematocrit, iron levels, and body weight, in the patient population we currently serve to help analyze the efficiency of their current HF regimen and help formulate any required adjustments to prevent future CHF exacerbation hospitalizations. Methods We retrospectively investigated all of our CardioMEMS patients who were hospitalized after CARDIOMEMS placement over a course of 1 year for CHF exacerbation. We followed them from baseline to hospitalization to discharge to clinic follow up while monitoring several variables, including pulmonary artery pressures, creatinine, pro-BNP, hematocrit, iron levels and body weight. All data was primarily collected via the Merlin.net™ Patient Care Network - Heart Failure Management Database and EPIC EMR. Necessary diuretic regimens were adjusted according to these variables. Results Our analysis showed a direct correlation with pulmonary artery pressure with pro-BNP and body weight and an inverse relationship with creatinine, iron levels, and hematocrit at the time of admission suggesting evidence of volume overload and increased ventricular wall stress. Pro-BNP displayed a strong, positive, relative linear relationship (Pearson Correlation of 0.609 and r of 0.63) and hematocrit had a similar inverse (strong, negative, linear) (Pearson Correlation of 0.713 and r of -0.58) relationship with pulmonary artery pressure, compared to the other variables. These variables displayed a similar inverse relationship as patients were adequately diuresed during their hospitalization and subsequently discharged home. We also saw 42% reduction in length of hospital stay and 56% 30 day readmission rates in our study patient population. Conclusion Our retrospective analysis confirmed that results endorsed by the CHAMPION trial by showing a significant reduction in hospitalization of our CardioMEMS patients. Concurrently, we also advocate the benefit of Pro-BNP and hematocrit levels as strong positive correlating factors to determine volume status.

The Benefits of Ambulatory Pulmonary Artery Pressure Monitoring in Patients With Heart Failure

CHAMPION trial showed a reduction in CHF hospitalizations with the utilization of the CardioMEMS device. We hope to expand on this trial by correlating pulmonary artery pressure to other variables of volume status, such as creatinine, pro-BNP, hematocrit, iron levels, and body weight, in the patient population we currently serve to help analyze the efficiency of their current HF regimen and help formulate any required adjustments to prevent future CHF exacerbation hospitalizations.

Ambulatory pulmonary artery pressure monitoring in advanced heart failure patients.

Heart failure (HF) is an emerging epidemic associate with significant morbidity, mortality, and health care expenditure. Although there were major advances in pharmacologic and device based therapies for the management of HF, mortality of this condition remains high. Accurate monitoring of HF patients for exacerbations is very important to reduce recurrent hospitalizations and its associated complications. With the failure of clinical signs, tele-monitoring, and laboratory bio-markers to function as early markers of HF exacerbations, more sophisticated techniques were sought to accurately predict the circulatory status in HF patients in order to execute timely pharmacological intervention to reduce frequent hospitalizations. CardioMEMSTM (St. Jude Medical, Inc., Saint Paul, Minnesota) is an implantable, wireless pulmonary arterial pressure (PAP) monitoring system which transmits the patient’s continuous PAPs to the treating health care provider in the ambulatory setting. PAP-guided medical therapy modification has been shown to significantly reduce HF-related hospitalization and overall mortality. In advanced stages of HF, wireless access to hemodynamic information correlated with earlier left ventricular assist device implantation and shorter time to heart transplantation.

328 - Ambulatory Pulmonary Artery Pressure Monitoring in Patients on Biventricular Mechanical Support—A Case Series

328 - Ambulatory Pulmonary Artery Pressure Monitoring in Patients on Biventricular Mechanical Support—A Case Series

Interventions Linked to Decreased Heart Failure Hospitalizations During Ambulatory Pulmonary Artery Pressure Monitoring

ObjectivesThis study sought to analyze medical therapy data from the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in Class III Heart Failure) trial to determine which interventions were linked to decreases in heart failure (HF) hospitalizations during ambulatory pulmonary artery (PA) pressure-guided management. BackgroundElevated cardiac filling pressures, which increase the risk of hospitalizations and mortality, can be detected using an ambulatory PA pressure monitoring system before onset of symptomatic congestion allowing earlier intervention to prevent HF hospitalizations. MethodsThe CHAMPION trial was a randomized, controlled, single-blind study of 550 patients with New York Heart Association functional class III HF with a HF hospitalization in the prior year. All patients undergoing implantation of the ambulatory PA pressure monitoring system were randomized to the active monitoring group (PA pressure-guided HF management plus standard of care) or to the blind therapy group (HF management by standard clinical assessment), and followed for a minimum of 6 months. Medical therapy data were compared between groups to understand what interventions produced the significant reduction in HF hospitalizations in the active monitoring group. ResultsBoth groups had similar baseline medical therapy. After 6 months, the active monitoring group experienced a higher frequency of medications adjustments; significant increases in the doses of diuretics, vasodilators, and neurohormonal antagonists; targeted intensification of diuretics and vasodilators in patients with higher PA pressures; and preservation of renal function despite diuretic intensification. ConclusionsIncorporation of a PA pressure-guided treatment algorithm to decrease filling pressures led to targeted changes, particularly in diuretics and vasodilators, and was more effective in reducing HF hospitalizations than management of patient clinical signs or symptoms alone.

Ambulatory pulmonary artery pressure monitoring during sleep and exercise in normal individuals and patients with COPD

Background: Pulmonary hypertension is a common complication of chronic obstructive airways disease (COPD) and its presence implies a poor prognosis. However, it is difficult to measure and its specific contribution...

Pulmonary artery pressure variation in patients with connective tissue disease: 24 hour ambulatory pulmonary artery pressure monitoring

BACKGROUNDThe specific contribution of secondary pulmonary hypertension to the morbidity and mortality of patients with underlying lung disease can be difficult to assess from single measurements of pulmonary artery pressure....

The Hemodynamic Significance of Asymptomatic ST Segment Depression Assessed by Ambulatory Pulmonary Artery Pressure Monitoring

The Hemodynamic Significance of Asymptomatic ST Segment Depression Assessed by Ambulatory Pulmonary Artery Pressure Monitoring

The haemodynamic significance of asymptomatic ST segment depression assessed by ambulatory pulmonary artery pressure monitoring.

A transducer-tipped catheter with simultaneous frequency modulated electrocardiograms and a miniaturised tape recorder was used to record ambulatory pulmonary artery pressure for 24-48 hours in 19 men (mean age 57.7) with clinical and angiographic evidence of coronary artery disease. Sixty seven episodes of ST segment depression (greater than 1 mm) were recorded. Thirty five were accompanied by pain of which six occurred at night; in 34 pulmonary artery diastolic pressure rose significantly. In all but two of the 32 episodes of painless ST segment depression (four of which were at night) there was a significant rise in pulmonary artery diastolic pressure. No such rise was found in six normal subjects during exertion. ST segment changes tended to occur before (24 episodes) or at the same time (27 episodes) as changes in pulmonary artery diastolic pressure. ST segment depression followed an increase in pulmonary artery diastolic pressure in only 13 episodes. The times to maximum ST depression and maximum pulmonary artery diastolic pressure rise were similar. Painful and painless ST segment depression could not be distinguished on the basis of the configuration of the ST segment or in terms of the changes in the pulmonary artery diastolic pressure.

The haemodynamic response to myocardial ischaemia in ambulant patients with variant angina.

The haemodynamic response to myocardial ischaemia in patients with variant angina during ambulatory activity is unknown. Ambulatory pulmonary artery pressure monitoring with a transducer tipped catheter and simultaneous frequency modulated electrocardiograms was used to assess changes in left ventricular function in five male patients (mean age 51.8 years) during variant angina; four patients had coronary artery stenosis and one had normal coronary arteries. Two hundred and seventy hours of ambulatory recordings were analysed. Twenty episodes (12 painful, 8 silent) of ST segment change greater than 1 mm occurred. Episodes tended to occur more frequently in the early morning hours. Six episodes of painful ST elevation were associated with a rise in pulmonary artery diastolic pressure. In the remaining episodes ST segment elevation was of shorter duration and there was no rise in pulmonary artery diastolic pressure. Pain was usually a late feature. Silent ST segment elevation occurred at rest and pulmonary artery diastolic pressure increased in all but one episode. Silent exertional ST segment depression was associated with a greater increase in pulmonary artery diastolic pressure than that seen during ST segment elevation. ST segment depression preceded or followed ST segment elevation in two episodes. The onset of ST segment elevation nearly always preceded the onset of a rise in pulmonary artery diastolic pressure. Ergometrine maleate provocation produced a rise in pulmonary artery diastolic pressure in three patients. In one there was no response to 1000 micrograms but spontaneous episodes of ST segment elevation were recorded during ambulatory monitoring. Treadmill exercise resulted in both ST segment elevation and depression with a similar haemodynamic response during both types of electrocardiographic change. When there is important coronary artery disease in two or more vessels ST segment changes may occur in different territories during treadmill exercise and during spontaneous episodes. Ambulatory pulmonary artery diastolic pressure monitoring is a useful technique for the investigation of variant angina.

Syndrome X: the haemodynamic significance of ST segment depression.

The relation between chest pain, ST segment depression, and changes in left ventricular function was assessed in six patients with angina, a positive exercise test, and normal coronary arteries as assessed by arteriography (syndrome X). In the six patients with syndrome X and in six controls there was no significant rise in pulmonary artery diastolic pressure during treadmill exercise, although there was ST segment depression (range 1-4.5 mm) in the patients with syndrome X. In 19 patients with coronary artery disease, however, the pulmonary artery diastolic pressure increased by a median 5 mm Hg (range 0-13.6 mm Hg) on treadmill exercise. In only one patient with coronary artery disease, who showed 1 mm ST segment depression, was there no rise in pulmonary artery diastolic pressure. During ambulatory monitoring in patients with syndrome X there were 12 episodes of ST segment depression (greater than 1 mm) (4 painful, 8 painless) in which there was no change in pulmonary artery diastolic pressure. In the patients with coronary artery disease there were 29 episodes of angina during ambulatory monitoring and during all of them pulmonary artery diastolic pressure rose by a median 7.5 mm Hg (range 1.8-19.7 mm Hg). Unlike the haemodynamic changes that usually occur during myocardial ischaemia in coronary artery disease, chest pain and ST segment changes in patients with syndrome X are not associated with impaired left ventricular function as assessed by ambulatory pulmonary artery pressure monitoring.

Haemodynamic response to myocardial ischaemia during unrestricted activity, exercise testing, and atrial pacing assessed by ambulatory pulmonary artery pressure monitoring.

Ambulatory pulmonary artery pressure monitoring by means of a transducer tipped catheter with a simultaneous frequency modulated electrocardiogram and a miniaturised tape recorder was used to study the haemodynamic implications of ST segment depression in patients with coronary artery disease. Nineteen male patients (mean (SD) age 58 (11) years) with clinical and angiographic evidence of coronary artery disease were studied together with six controls. Changes in the ST segment and pulmonary artery diastolic pressure during treadmill exercise, atrial pacing, and unrestricted ambulant activity were analysed. During exercise, pulmonary artery diastolic pressure rose significantly in patients with coronary artery disease but not in the controls. One patient with ST depression greater than 1 mm did not have a rise in pulmonary artery diastolic pressure on exercise; two had a rise in pulmonary artery diastolic pressure with no ST segment change despite severe angina. The pulmonary artery diastolic pressure tended to rise before or simultaneously with the onset of ST segment depression. The haemodynamic response to atrial pacing was similar in normal controls and patients with coronary artery disease. During ambulatory monitoring there were 29 episodes of ST segment depression all of which were associated with a rise in pulmonary artery diastolic pressure and chest pain. The onset of ST segment depression occurred before a rise in pulmonary artery diastolic pressure in 11 episodes, was simultaneous with it in 11, and followed it in seven episodes. During exercise and ambulatory monitoring there was a correlation between the magnitude of ST segment depression and the rise in pulmonary artery diastolic pressure. Pain was a late feature during exercise, atrial pacing, and anginal episodes. This technique for the first time allows the relation between ST segment changes and haemodynamic alterations in left ventricular function to be assessed in ambulant patients with coronary artery disease.

Continuous ambulatory pulmonary artery pressure monitoring. A new method using a transducer tipped catheter and a simple recording system.

A transducer tipped catheter and simple recording system were used for the continuous measurement of ambulatory pulmonary artery pressure. The pulmonary artery pressure was recorded on a miniaturised tape recorder and replayed via an optical writer. Pulmonary arterial systolic and diastolic pressures can be analysed on a beat to beat basis. Continuous ambulatory monitoring was performed for a total 288 hours in 13 patients who were undergoing routine investigation for coronary artery disease. There was less than 1% zero drift and 0.25% linearity error per full scale pressure. The frequency response of the entire system was flat to 8 Hz with a linear phase delay. The transducer tipped catheter and a conventional fluid-filled system were used to measure left ventricular and pulmonary artery end diastolic pressures in eight patients. The correlation between the results obtained by the two methods was excellent. This method could be used at any centre equipped for ambulatory electrocardiographic monitoring.

The Significance of St Segment Depression in Syndrome X Assessed by Ambulatory Pulmonary Artery Pressure Monitoring

The Significance of St Segment Depression in Syndrome X Assessed by Ambulatory Pulmonary Artery Pressure Monitoring