Nikhil Narang1, Ben Chung1, Ann Nguyen1, Rohan J Kalathiya1, Luke J Laffin2, Luise Holzhauser1, Imo A Ebong1, Stephanie A Besser1, Teruhiko Imamura1, Bryan A Smith1, Sara Kalantari1, Jayant Raikhelkar3, Nitasha Sarswat1, Gene H Kim1, Valluvan Jeevanandam4, Daniel Burkhoff5, Gabriel Sayer3, Nir Uriel6. 1. Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637. 2. Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code JB1, Cleveland, Ohio 44195. 3. Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032. 4. Department of Surgery, Section of Cadiac Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637. 5. Columbia University Medical Center and Cardiovascular Research Foundation, 1700 Broadway, 9th floor, New York, NY 10019. 6. Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032. Electronic address: nu2126@cumc.columbia.edu.
Abstract
BACKGROUND: Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. METHODS AND RESULTS: We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). CONCLUSIONS: Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.
BACKGROUND: Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. METHODS AND RESULTS: We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). CONCLUSIONS: Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.
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