Echo-Doppler and clinical evaluations to define hemodynamic profile in patients with chronic heart failure: accuracy and influence on therapeutic management

Background: Correct classification of chronic heart failure (CHF) patients by dual evidence of congestion and adequate perfusion is the primary clinical focus for management. Objectives: To evaluate the accuracy of echo-Doppler compared with clinical evaluation in determining the hemodynamic profile of patients with CHF; and to compare therapeutic changes based on hemodynamic or echo-Doppler findings. Methods: Three hundred and sixty-six consecutive CHF patients (ejection fraction 25 7%) in sinus rhythm, undergoing evaluation for cardiac transplantation, underwent physical examination prior to right heart catheterization and echo-Doppler studies. Subsequently, patients were randomized to therapeutic optimization using either right heart catheterization or echo-Doppler data. The end-points were: identification of low cardiac output (cardiac index < 2.2 l/min/m(2)); high pulmonary wedge pressure (PWP > 18 mm Hg); high right atrial pressure (RAP > 5 mm Hg) and analysis of therapeutic changes made in response to the right heart catheterization and echo-Doppler studies. Results: Echo-Doppler showed better accuracy in estimating abnormal hemodynamic indices than clinical variables (cardiac index < 2.2 l/min/m(2): echo positive predictive accuracy (PPA) 98% vs. clinical PPA 52% p < 0.00001; PWP > 18 mm Hg: echo PPA 85% vs. clinical PPA 76% p = 0.0011; RAP > 5 mm Hg: echo PPA 82% vs. clinical PPA 57% p < 0.00001). When applied to individual patients, the echo-Doppler assessment was more accurate than clinical evaluation in defining the different hemodynamic profiles: wet/cold (89% vs. 13%, p < 0.0001); wet/warm (73% vs. 30%, p < 0.0001); dry/cold (68% vs. 12%, p < 0.0001); dry/warm (88% vs. 51%, p < 0.0001). Therapeutic decision-making based on echo-Doppler findings was similar to that based on hemodynamics. Conclusion: Echo-Doppler hemodynamic monitoring proved accurate in estimating hemodynamic profiles and influenced therapeutic management. (c) 2004 European Society of Cardiology. Published by Elsevier B.V All rights reserved.