IL MONITORAGGIO EMODINAMICO NELLO SCOMPENSO CARDIACO

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IL MONITORAGGIO EMODINAMICONELLO
SCOMPENSO CARDIACO

• a cura di
• Fabrizio Oliva

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

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

AREA SCOMPENSO A.N.M.C.O.,
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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 () lt1 2
Pulmonary artery catheter () 5 17
Dialisys () 5 9
AREA SCOMPENSO A.N.M.C.O.
AREA SCOMPENSO A.N.M.C.O.
Kirkwood et al Am Heart J 2005
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ANMCO Survey on Acute Heart Failure
IN-HOSPITAL PROCEDURES (2807 patients)
AREA SCOMPENSO A.N.M.C.O.
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Evaluation Study of Congestive Heart Failure and
Pulmonary Artery Catheterization
EffectivenessThe 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 1625-33
AREA SCOMPENSO A.N.M.C.O.
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The ESCAPE Trial
Impact of Intervention on Primary End Point
Across Demographic Subgroups
JAMA 2005 294 1625-33
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The ESCAPE Trial
Primary 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 FailurePulmonary Artery
Catheter (PAC)

• The insertion for diagnosis of AHF is usually
  unnecessary
• It can be use to distinguish between a
  cardiogenic and a non-cardiogenic mechanism in
  complex pts with concurrent cardiac and pulmonary
  disease
• It is also used to estimate haemodynamic variable
  in the presence of severe diffuse pulmonary
  pathology or ongoing haemodynamic compromise not
  resolved by initial therapy.

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2005 ESC Guidelines on the Diagnosis and
Treatment of Acute Heart FailurePulmonary 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 C
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Monitoraggio Emodinamico nello S.C.
acutoCONCLUSIONI

• 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