Pulmonary artery catheter use increased in heart failure despite recommendations

1. There was an increase in pulmonary artery catheterization in heart failure patients despite the ESCAPE trial’s recommendations against its use.

2. The largest increase was found in patients without a definite indication.

Evidence Rating Level: 2 (Good)

Study Rundown: Pulmonary artery (PA) catheters are used for continuous cardiac output monitoring and was thought to be helpful in patients with heart failure (HF). However, after the ESCAPE trial in 2005, it was shown that PA catheters in HF management did not improve outcomes and in fact was associated with an increase in adverse events. Thereafter, guidelines recommended against the use of PA catheterization in HF patients. It is unclear, however, how well these recommendations have been implemented. This study examined the contemporary trends of PA catheter use in hospitalized HF patients.

Initially, there was a decrease in PA catheter use from 2001 to 2007. However, in contrast to the ESCAPE trial results, there was an increase in PA catheter use in hospitalized HF patients thereafter to 2012. Interestingly, the largest increase was found in patients without a definite indication. Strengths of this study include using validated diagnostic and procedural coding to capture a large study population, and it also highlights the known issue of efficient guideline implementation into practice. However, this study did not address the concern of whether the increase of PA catheterization was attributed to inappropriate use, and thus further study may be warranted.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness (ESCAPE Trial)

In-Depth [survey analysis]: This study completed a survey analysis from the National Inpatient Sample identifying adult patients from January 2001 to December 2012. The population of study was patients with a diagnosis of HF using the validated International Classification of Disease 9^th Revision (ICD-9-CM) codes. Using validated procedural codes, the study authors identified hospitalized HF patients where PA catheters were used. The authors then examined changes in the use of PA catheters among HF patients before (2001 to 2006) and after (2006 to 2012) the ESCAPE Trial. Subgroup analyses included investigation of patient cohorts with cardiogenic shock, mechanical ventilation with no cardiogenic shock, and HF without respiratory or cardiogenic failure.

Over the whole study period, 75,000 hospitalizations for heart failure were associated with PA catheter use. This represented 0.6% of all HF hospitalizations. There was an initial overall decrease in PA catheterization from 2001 to 2007, from 7.9 to 4.9 per 1000 HF hospitalizations. However, from 2007 to 2012, there was an increase back to 7.9 per 1000 HF hospitalizations. In subgroup analysis, both patient groups with cardiogenic shock only, and those without cardiogenic shock or respiratory failure, had significant initial decreases from 2001 to 2007. However, thereafter, both groups had significant increases to 2012. In contrast, patients with respiratory failure only had a significant decrease in PA catheter use from 2001 to 2012.

Image: PD

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