Discordance Between Clinical Assessment And Invasive Hemodynamics In Patients With Advanced Heart Failure

N Narang, B Chung, A Nguyen, RJ Kalathiya, LJ Laffin, L Holzhauser, IA Ebong, SA Besser, T Imamura, BA Smith, S Kalantari, J Raikhelkar, N Sarswat, GH Kim, V Jeevanandam, D Burkhoff, G Sayer and N Uriel
J Card Fail 2019

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 versus. invasive hemodynamics in patients with ADHF.

METHODS AND RESULTS: We conducted a prospective cohort study of patients admitted with ADHF. Prior to RHC, physicians categorically predicted right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI) and hemodynamic profile (Wet/Dry, Warm/Cold) based on physical exam and clinical data evaluation. “Warm”= CI > 2.2 L/min/m(2); “Wet”=PCWP >18 mmHg. 218 surveys (83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients were collected. 46% were receiving inotropes prior to RHC. Positive and negative predictive values of clinical assessment compared to RHC for the “Cold and Wet” subgroup were 74.7% and 50.4%. Accuracy of categorical prediction was 43.6% for RAP, 34.4% for PCWP, 49.1% for CI, and 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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