IL MONITORAGGIO EMODINAMICONELLO SCOMPENSO CARDIACO

a cura di Fabrizio Oliva

AREA SCOMPENSO A.N.M.C.O.

Pulmonary Artery Catheter (PAC)

• Introduction in 1970s• PAC is often considered a cornerstone of critical care and

a hallmark of the ICU• Appoximately 1 million PACs are used annualy in US• Physician, equipment and hospital cost in US over $ 2

billion per year• Widspread application in the ICU and perioperative

setting, despite a lack of high-quality evidence supporting such use

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Pulmonary Artery Catheter (PAC)

Conflicting Data• The majority of nonrandomized study in critically ill pts have suggested

that PAC is associated with increased morbidity and mortality• Conversely some studies showed improved quality of life when the PAC

was used to direct a specific therapeutic approach• Limits: small sample sizes in heterogeneous populations• Clinicians continue to use the PAC in ICUs based on personal

experience and the belief that careful monitoring will improve decision making and clinical outcome.

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ADHERE Registry

Procedure All patients

(N= 105.388)

ICU patients

( N= 19754)Defibrillation (%) 1 6

Mechanical ventilation (%)

5 23

Intraaortic baloon pump (%)

<1 2

Pulmonary artery catheter (%)

5 17

Dialisys (%) 5 9

Kirkwood et al Am Heart J 2005

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IN-HOSPITAL PROCEDURES(2807 patients)

n. %Echocardiogram 2580 91.9Holter monitoring 449 16.0Left cath 487 17.4Right cath 101 3.6Exercise test 58 2.1Echo Stress 64 2.3Myocardial biopsy 5 0.2

ANMCO Survey on Acute Heart Failure

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Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness

The ESCAPE Trial

- 433 pts- 56 y (SD14)- 74% male- ischemic 51%- EF 20% (SD 6)- Creat 1.5 mg/dl (SD0.6)

JAMA 2005; 294: 1625-33AREA SCOMPENSO A.N.M.C.O.

The ESCAPE Trial

Impact of Intervention on Primary End Point Across Demographic Subgroups

JAMA 2005; 294: 1625-33AREA SCOMPENSOA.N.M.C.O.

The ESCAPE TrialPrimary Outcomes Mortality and Hospitalizations and Primary End Point Results by

Inotrope and Vasodilators Use After Randomization

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2005 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure

Pulmonary Artery Catheter (PAC)

• Its use is reccomended in haemodinamically unstable pts who are not responding in a predictable fashion to traditional treatments and in pts with a combination of congestion and hypoperfusion.

• It is inserted in order to ensure optimal fluid loading of the ventricles and to guide vasoactive therapies and inotropic agents.

• Because the complications increase with the duration of its use, it is critical to insert the PAC when specific data are neeeded and to remove it as soon as it is of no further help.

Class IIb reccomandation, level of evidence CAREA SCOMPENSOA.N.M.C.O.

Monitoraggio Emodinamico nello S.C. acuto

CONCLUSIONI:• E’ utilizzato in una bassa percentuale di pz. ricoverati per IC• Un impiego estensivo non è in grado di migliorare la gestione e il destino

nella maggior parte questi pz.• La procedura è esente da rischi rilevanti, soprattutto presso centri con ampia

esperienza.• Utilizzo oculato per rispondere a una precisa esigenza diagnostica e/o

terapeutica:– diagnosi dubbia– persistenza di sintomi nonostante terapia– combinazione di congestione ed ipoperfusione– difficoltà allo svezzamento da terapia infusiva– Ipertensione polm. non reversibile a test acuto in candidato a Txc

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