The best way to measure congetion

1. The Best Way To Measure Congestion
 What site and what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

2. Confidential C 2
ACC/AHA Guidelines for HF Management
3. Volume status and vital signs should be assessed at each
patient encounter. This includes serial assessment of
weight, as well as estimates of jugular venous pressure
and the presence of peripheral edema or orthopnea
(Level of Evidence: B)
6.1. Clinical Evaluation
Class I Recommendation
A Report of the American College of Cardiology
Foundation/American Heart Association
Task Force on Practice Guidelines - 2013

3. Assessment of Congestion:
Where and With What Response?

4. Preventing HF Re-Admissions:
The “Best” Care is Not Good Enough
 National HF readmission rates over 20% at 1 month
 Pts called at 1-2 days, seen at 7-14 days
 Re-education regarding Na restriction + fluid limit
 Monitor daily weights: 2 pound increase – 2 Xe diuretic dose
(or “metolazone booster”) until resolved
 Phone number to call for symptoms or weight gain

5. No
orthodema
52%Low-grade
orthodema
32%
High-
grade
orthodema
16%
Discharge
a
No
orthodema
35%
Low-grade
orthodema
27%
High-
grade
orthodema
38%
60-day Follow up
De-congestion and Re-Congestion After Hospitalization
Lala, Mentz, Vader for HFAN
From NHLBI Heart Failure Network Trials
Under revision for Circ HF

6. Pressure Rises Early In Decompensation
Same Course Tracked with Different Devices
Adamson P, et al. European Heart Journal (2012) 33 (Abstract Supplement), 650-651.
6
Bourge et al, from COMPASS trial
2009, Chronicle device in RV
RV Diastolic Pressure
Adamson et al, 2012
CARDIOMEMS device in PA

7. The Gathering Storm
Why are we missing it?

8. Assessment of Congestion:
Where and With What Response?
???

9. Most Days of Heart Failure Management
Are Blind
HF Clinic
Device Clinic
Home

10. The Best Way To Measure Congestion
 What site for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

11. Response and
Re-assessment
Right
Signal
Right Action
Monitoring To Avert Decompensation
Need for Iteration and Simplicity

12. Listening For Reports of Edema and Weight Changes:
Many patients never get edema
despite severe volume overload,
particularly in patients < 65 yrs
Edema usually indicates > 4 pounds of
fluid retention.
Weight often does not change as fluid
increases, if appetite decreases.
Weight may increase over longer
period when patients eat better.

13. < 2 lbs
3 to 5
6 to 10
> 10
Patients admitted with HF:
Most had < 2 lbs weight gain
Chaudry, Wang, Concato, Gill, Krumholz
Circulation 2007: 116: 1549-54
Most HF Hospitalizations
Were Not Preceded by Obvious Weight Gain
Listening To More Weights and Symptoms
Did Not Decrease Admissions
Chaudry, Mettera, Curtis, Spertus, Herrin, Lin,
Phillips, Hodson, Cooper, Krumholz. NEJM 2010:363:2301-9

14. With Good HF Management, Increases in Pulmonary Artery Pressures
(But Not Body Weight) Precede Hospitalization for Heart Failure
lbs
mmHg
Body Weight RV Diastolic Pressure
Data from the COMPASS trial
Bourge et al

15. I
For the right signal,
Wisdom it is not
To weight.

16. The Best Way To Measure Congestion
 What site for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressure-guided therapy includes both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

17. Medication Changes During 6 Months:
Blind Vs Monitored
Blind Therapy Monitored Therapy
Total med changes 1061 2517 p<0.0001
Diuretic changes 585 1547 p< 0.0001
per pt/month 0.3 0.8
Nitrate dose change
(mean/day)
+ 4 mg + 18 mg p< 0.04
Hydralazine change +22 mg + 33 mg NS
ACEI change 0 mg + 4 mg p< 0.01
Beta blocker +0.6 +3.4 mg p<0.05
Costanzo, HFSA 2011

18. Increasing Benefit to Decrease HF Hospitalization
Annualized 33% decrease
In hospitalizations
NNT = 4 to prevent 1 hosp

19. 49.8 50.2
75.4
24.6
0
10
20
30
40
50
60
70
80
%ofMedicationsChanges
w-PAP Increases w-PAP Decreases
Medications Adjustments
in Response to w-PAP Changes
Diuretics
Other Medications
629 633
107 35
Diuretics and vasodilators
used when pressures high
Diuretics changed when
pressures decreased.
Costanzo et al, HFSA 2011

20. The Best Way To Measure Congestion
 Where and for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

21. Heart Failure Events Develop Slowly Regardless
of LVEF
25
27
29
31
33
35
37
-70 -60 -50 -40 -30 -20 -10 0 10 20
Time (days)
ePAD(mmHg)
Heart Failure
Related Event
Heart failure low EF
Heart failure preserved EF
21 days
Zile et al
COMPASS Investigators
Circulation 2008

22. Benefit of Pressure-Guided Strategy
in Champion Trial
Extends to HF with Preserved EF
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Reduced EF Preserved EF
Control Hosp
Champion Hosp
Hazard Ratio
Adamson P et al, Circ Heart Failure, 2014
N=430 N=119
Rate of Hospitalzations
And Reduced Hazard Ratio
for Monitored Patients

23. DHF Patients
Mean ePAD Pressure through:firstHF event(eventpatients),randomized follow-up (non-eventpatients)
Log(Hazard)
10 20 30 40 50
-2-1012
2515
SHF Patients
Mean ePAD Pressure through:firstHF event(eventpatients),randomized follow-up (non-eventpatients)
Log(Hazard)
10 20 30 40 50
-3-2-1012
2515
HF with Preserved EF
HF with Low EF
Optimal daily
filling pressures for
HFpEF:
Not enough data
yet to know if
the curve is U-shaped
Circulation HF
2010
Likelihood
Of HF Events
Daily PAD pressures
Daily PAD pressures
mm

24. The Best Way To Measure Congestion
 Where and for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

25. Congestion is Not Just a Symptom
Disease Progression
 All the correlates of congestion are the strongest
predictors of mortality.
 Congestion leads to hospitalizations which correlate
with higher mortality.
 Congestion in the left heart leads to pulmonary
hypertension which loads the right ventricle.
 High right atrial pressures are linked to the
cardiorenal syndrome.
 Right heart failure is the major harbinger of
increasing morbidity and mortality in advanced heart
failure.

26. The Right Ventricle -
The Tipping Point
As pulmonary hypertension develops,
RV dysfunction begins to be detectable
when PAD pressures exceed 20 mm Hg.

27. Median Daily ePAD mmHg
Circ Heart Fail. 2010 Sep;3(5):580-7..
Probability of HF Event Related to
Estimated PA Diastolic Pressure Plateau

28. Risk of HF Event Related to Baseline PA Pressures –
CHAMPION
Impact of home PA pressure
monitoring
Baseline pressures
known for all patients
Costanzo et al
HFSA 2011

29. CHAMPION Trial:
All Secondary Efficacy Endpoints Met
Abraham WT, Adamson PB, Bourge RC, et al: Lancet 2011;377:658

30. Stage A. Diuretics Help Prevent Heart Failure from HTN
Not Just for Symptoms
0
0.2
0.4
0.6
0.8
1
Vs Placebo Vs ACEI Vs ARB Vs Bblockers
HF Risk All CVD Events
Psaty BM, Lumley T, Furberg CD,
Pahor M, Alderman MH, Weiss NH.
JAMA 2003: 289: 2534-44
“Low-dose diuretics are the most effective (+cost-effective) first-line therapy
for preventing the occurrence of cardiovascular morbidity and mortality.”

31. The Best Way To Measure Congestion
 Where and for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

32. COMPASS Trial: Treatment for Increasing PA Pressures
Decreased Risk of HF Hospitalization
But Not Enough
HR = 0.64 [0.42 - 0.96], p=0.03
0 50 100 150 200
0.0
0.2
0.4
0.6
0.8
1.0
124 120 108 101 93 89 84 4
Number at Risk
132 119 110 91 87 80 77 3
Hemonitoring
CONTROL
FreedomfromHospitalization
Days from Randomization
Hemodynamic monitoring
CONTROL
Home monitored
pressures
Better but not good enough?

33. Increasing Benefit to Decrease HF Hospitalization
Annualized 33% decrease
In hospitalizations
NNT = 4 to prevent 1 hosp

34. Treat the peaks
Lower the plateau
Level the valleys
Three Targets for Ambulatory Pressures

35. Symmetric Strategy Includes
Adjusting Diuretics Up AND Down
The “Right Dose” for Every Day
Ritzema et al
Circ 2010;121: 1086-95
Physician-Directed Patient Self-Management of LAP
in HOMEOSTASIS Trial
Guided Care Changes (6 mos)
Cp to Observation Period (3 mos)
Daily Diuretic Dose 27%
From 151 to 109 mg
Diuretic Changes on 53% of days:
Higher on 29% of days
Lower on 24% of days
Neurohormonal Therapies To Modify
Disease:
ACEI/ARB Dose 37%
Beta blocker
Dose
40%

36. Response and
Re-assessment
Right
Signal
Right Action
Monitoring for Congestion:
Empower the Patient for Self-Management
Into the hands
of the patient

37. The Best Way To Measure Congestion
 Where and for what intervention?
 Most days for patients are not clinic days.
 The right congestion signal from home is early, actionable, and responsive
 Therapy guided by home pressures > therapy guided by other changes
 Pressures respond to both diuretics and vasodilators.
 Pressure-guided strategy also addresses HF with preserved EF
 Any strategy that averts re-congestion should decrease HF progression to cardio-renal
impairment and right heart failure.
 Do we aim for optimal pressures or wait until something gets worse?

38. The
Cardio-Renal
Syndrome
RA
RV Equally common with heart failure
Low EF and HF preserved EF
The major hemodynamic correlates
are tricuspid regurgitation and
high right atrial pressures.