IL MONITORAGGIO EMODINAMICO NELLO 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 AREA SCOMPENSO A.N.M.C.O.

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.,

ADHERE Registry Procedure All patients (N= 105.388) ICU patients Defibrillation (%) 1 6 Mechanical ventilation (%) 5 23 Intraaortic baloon pump (%) <1 2 Pulmonary artery catheter (%) 17 Dialisys (%) 9 AREA SCOMPENSO A.N.M.C.O. AREA SCOMPENSO A.N.M.C.O. Kirkwood et al Am Heart J 2005

IN-HOSPITAL PROCEDURES ANMCO Survey on Acute Heart Failure IN-HOSPITAL PROCEDURES (2807 patients) AREA SCOMPENSO A.N.M.C.O.

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

The ESCAPE Trial Impact of Intervention on Primary End Point Across Demographic Subgroups JAMA 2005; 294: 1625-33

Inotrope and Vasodilators Use After Randomization The ESCAPE Trial Primary Outcomes Mortality and Hospitalizations and Primary End Point Results by Inotrope and Vasodilators Use After Randomization

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

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 C

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