© 2005 European Society of Cardiology
Echo-Doppler and clinical evaluations to define hemodynamic profile in patients with chronic heart failure: accuracy and influence on therapeutic management
a Fondazione "Salvatore Maugeri" IRCCS, -PAVIA-Istituto Scientifico di Montescano, Italy
b Policlinico di Monza Milano, Italy
* Corresponding author. Department of Cardiology, Montescano Medical Center, Via per Montescano 27040 Montescano-Pavia, Italy. Tel.: +39 385 2471; Fax: +39 385 61386. E-mail address: scapomolla{at}fsm.it
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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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/m2); 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/m2: 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.
Key Words: Echo-Doppler • Chronic heart failure • Clinical signs
Received September 4, 2003; Revised March 18, 2004; Accepted July 5, 2004
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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Increase in cardiac output, decrease in capillary pulmonary pressure and right atrial pressure and improvement of clinical symptoms are strategic objectives for the physician in the management of patients with CHF [1]. However, recent studies have shown that bedside clinical evaluation of the CHF patient has limitations for accurately predicting the patient's hemodynamic profile [2,3]. Invasive hemodynamic monitoring can be used to aid the management of patients with acute heart failure; however, the risks of this approach must be considered, since the use of right heart catheterization to guide and monitor unloading therapy in critically ill patients has been associated with an increase in mortality [4].
Color Doppler echocardiography has great potential; it can define the etiology of cardiomyopathy, differentiate the degree of systolic and/or diastolic left ventricular dysfunction and also permit non-invasive evaluation of the hemodynamic profile to guide therapeutic decision-making [5]. However, few studies have analyzed the predictive accuracy of echo-Doppler findings compared to clinical examination, in the evaluation of the hemodynamic profile of the CHF patient. Moreover, there are no daconcerning the relationship between non-invasively assessed hemodynamic profile and the management algorithm for CHF. We performed this study to evaluate the accuracy of echo-Doppler compared with clinical evaluation in determining the hemodynamic profile of CHF patients and to compare changes in therapy according to the hemodynamic or echo-Doppler findings.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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2.1. Patients
Four hundred and seventy-six consecutive patients with CHF, caused by ischemic or idiopathic-dilated cardiomyopathy, admitted to our Heart Failure Unit for evaluation and treatment of advanced heart failure, were enrolled in the study. Dilated cardiomyopathy was defined by two-dimensional echocardiographic demonstration of a dilated left ventricle (left ventricular end-diastolic volume index >68 ml/m2) with severe left ventricular systolic dysfunction (ejection fraction <40%).
Patients with technically inadequate Doppler echocardiographic recordings (22 pts), and those with atrial fibrillation (58 pts) and/or prosthetic valves (30 pts) were excluded. Clinical, hemodynamic and Doppler echocardiographic characteristics of all patients included in the study (n=366) are reported in Table 1.
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2.2. Study protocol
The protocol was composed of the following two phases.
2.2.1. Phase 1: Comparison of echo-Doppler and clinical variables in predicting hemodynamic variables
Patients with refractory heart failure and with a stable hemodynamic profile, referred to our Heart Failure Unit, underwent therapeutic optimization based on clinical findings. Subsequently, when the patient was in a stable clinical condition and after weaning from intravenous infusions, hemodynamic and echo-Doppler examinations were performed. All patients underwent a complete physical examination, echo-Doppler and right heart catheterization. These investigations were performed within 2 h of each other. Clinical evaluations were performed by four physicians blind to the hemodynamic and echo-Doppler findings. Echocardiographic and hemodynamic evaluations were performed by two physicians blind to the clinical and echo-Doppler or hemodynamic results. In this phase of the study, we evaluated the accuracy of clinical and echo-Doppler variables in predicting hemodynamic indices. Moreover, in patients with different degrees of diastolic and systolic dysfunction we analyzed the reliability of clinical and echo-Doppler evaluations in discriminating the following hemodynamic profiles: (1) wet/cold (cardiac index <2.2 l/min/m2; PWP >18 mm Hg); (2) dry/cold (cardiac index <2.2 l/min/m2; PWP <18 mm Hg); (3) wet/warm (cardiac index >2.2 l/min/m2; PWP >18 mm Hg); (4) dry/warm (cardiac index >2.2 l/min/m2; PWP <18 mm Hg).
2.2.2. Phase 2: Comparison of therapy optimization based on hemodynamic or echo-Doppler information
This phase of the study started immediately after phase 1. Patients were randomized to either therapeutic optimization using the clinical and hemodynamic data (three physicians, 267 patients), or therapeutic optimization using clinical and echo-Doppler information (1 physician, 99 patients). During this phase, the patients received the maximum tolerated dose of ACE-inhibitors, digitalis, beta-blockers and nitrates.
2.3. Cardiac catheterization
Right heart catheterization was carried out using a 7 F Swan-Ganz balloon-tipped catheter inserted into the right internal jugular vein and advanced through the right heart cavities into the pulmonary artery. Fifteen minutes after the catheter insertion, measurements were obtained with the patient in a supine position, using an HP transducer connected to a 7005 Marquette polygraph. Pressure tracings were recorded at a speed of 50 cm/s on a scale calibrated from 0 to 60 mm Hg.
Cardiac output was determined by averaging three thermal dilution curves obtained by injecting 10 ml of saline solution at 0 °C into the right atrium.
Right atrial pressure, pulmonary artery pressures and mean pulmonary wedge pressure were recorded. Arterial systolic and diastolic blood pressures were measured non-invasively using a calibrated v-lok-cuff connected to a 7005 Marquette system.
Heart rate, determined from a standard ECG lead, was monitored continuously.
2.4. Echocardiography
Echocardiographic studies were performed using an HP Sonos 1000 ultrasound system with 2.5 and 3.5 MHz transducers. Combined 2-D and M-Mode echocardiographic examinations were performed with the patient lying in a supine position, before starting the right heart catheterization. The echo-Doppler criteria for defining the hemodynamic profile were derived from our previous experience and from published data [5–8].
2.4.1. Pulmonary wedge pressure
Mitral flow velocity was obtained from a two-dimensional apical window with a pulsed wave technique by placing the sample volume between the tips of the mitral leaflets. The following variables were calculated over five consecutive cycles: maximal velocity, deceleration time (DT) of early diastolic filling (E); maximal velocity of late diastolic filling (A); the ratio of maximal early to late diastolic filling velocities (E/A). Pulmonary venous flow was determined from an apical four-chamber view. After identification of the pulmonary vein with color-Doppler, a sample volume was set about 1 cm into the upper right pulmonary vein. Averaging five consecutive cardiac cycles, peak velocities of forward systolic (X) and diastolic flow (Y) were measured and the systolic fraction of forward pulmonary vein flow (SFpvf), (X/(X+Y))%, was calculated. E/A >1, DT <130 and SFpvf <40% identified patients with a pulmonary wedge pressure >18 mm Hg; E/A <1 or E/A >1, DT >130 and SFpvf >40% identified those with a pulmonary wedge pressure <18 mm Hg.
2.4.2. Cardiac output
The stroke volume was evaluated by the left ventricular outflow method. The diameter of the left ventricular outflow at the aortic annulus was measured in the parasternal long-axis view. The aortic area was then calculated using the formula: 
2. Three measurements were averaged. The velocity of aortic flow was evaluated by pulsed-wave Doppler from the apical five-chamber view. The sample volume was positioned in the middle of the outflow tract below the aortic cusps and the time velocity integrals were recorded. Five consecutive cycles were digitized using the leading edge method. The cardiac output was calculated using the following formula: 2xVTIxheart rate.
2.4.3. Right atrial pressure
Two-dimensional echocardiograms of the inferior vena cava were obtained from subxiphoid views. The transducer was held and translated to obtain clear inferior vena cava images; in this setting, the beam direction to obtain M-Mode scanning was positioned by track-ball perpendicularly to the long axis of the inferior vena cava within 2 cm of its entry into the right atrium. Using the respiratory trace, which mirrors the movement of the diaphragm during respiration, the maximal and minimal diameters of the inferior vena cava in the late diastolic phase were measured. The index ‘collapse of inferior vena cava—, which identifies the percent decrease in diameter of the inferior vena cava during quiet inspiration, was calculated as the difference of diameters to maximal diameter ratio percent. A collapse of inferior vena cava <40% and/or a minimal diameter of inferior vena cava >12 mm identified a right atrial pressure >5 mm Hg; conversely, a collapse of inferior vena cava >40% and/or a minimal diameter of inferior vena cava <12 mm identified a right atrial pressure <5 mm Hg.
2.5. Clinical evaluation
Several signs and symptoms assessed during the physical examination were used to estimate the hemodynamic profile [9].
2.5.1. Cardiac output
This variable was estimated from the proportional pulse pressure (PP). It was measured as the percentage of systolic and diastolic pressure difference to systolic artery pressure ratio (PP%); a PP <25% identified patients with a cardiac index of <2.2 l/min/m2, whereas a PP >25% characterized patients with a cardiac index >2.2 l/min/m2 [2].
2.5.2. Pulmonary wedge pressure
The presence of a third heart sound and/or rales and/or orthopnea was used to identify patients with a pulmonary wedge pressure >18 mm Hg.
2.5.3. Right atrial pressure
Raised jugular venous pressure and/or hepato-jugular reflux was used to classify patients as having a right atrial pressure >5 mm Hg.
2.5.3.1. Statistical analysis
Descriptive statistics are presented as means±S.D. A probability value of <0.05 was used to reject the null hypothesis. Between-group comparisons of baseline clinical and functional variables and of therapeutic changes were performed by one-way ANOVA for continuous variables and by the chi-square test for categorical variables. The E/A ratio, deceleration time of early diastolic filling, and systolic fraction of pulmonary venous flow were also considered as continuous and dichotomous variables with cut-off values of >1, DT <130 ms and SFpvf <40%, respectively. The cut-off values were obtained by sensitivity analysis which identified the best values for predicting anomalous values (PWP >18 mm Hg; RAP >5 mm Hg) with regard to model fitting criteria (likelihood ratio based statistics and Wald statistics) and prediction criteria. We calculated the sensitivity, specificity and predictive accuracy of the clinical and echo-Doppler variables in identifying a pathologic hemodynamic profile.
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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3.1. Hemodynamic findings
The study group comprised 366 patients (329 men and 37 women) with a mean age of 53±8 years. The etiology of heart failure was ischemic heart disease in 168/366 (46%) of patients and idiopathic cardiomyopathy in 198/366 (54%). Systolic pulmonary artery pressure was raised in 114 patients. Table 1 summarizes the mean baseline values in all patients. In 199/366 (54%) patients, the cardiac index was <2.2 l/min/m2. A pulmonary wedge pressure> 18 mm Hg was recorded in 180/366 (49%) of patients. Right atrial pressure was raised in 96/366 (26%). The hemodynamic profiles found in our population are shown in Table 2.
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3.2. Prevalence of clinical signs and symptoms
Proportional pulse pressure was decreased in 95/366 (26%) patients, indicating decreased cardiac output.
A third heart sound was heard in 91/366 (25%) of patients; rales were audible in 37/366 (10%) and 102/366 (28%) of the patients evaluated had orthopnea. Of these three criteria used to identify patients with a pulmonary wedge pressure >18 mm Hg, 102/366 (28%) had 1 criterion, 51/366 (14%) had 2 criteria and 25/366 (7%) fulfilled all three criteria.
Jugular venous pressure was raised in 80/366 (22%) patients; hepato-jugular reflux was induced in 150/366 (41%) and hepatomegaly was found in 132/366 (36%) of the patients. Thus, of these three criteria used to identify a right atrial pressure >5 mm Hg, 150/366 (41%) of the patients had 1 criterion, 48/366 (13%) had 2 criteria and 26/366 (7%) patients had all three criteria.
3.3. Prevalence of echocardiographic findings
A restrictive mitral flow pattern was recorded in 133 (36%) patients. A non-restrictive mitral flow pattern was recorded in 223 (61%). Mitral flow pattern was not measured in 10 (3%) patients. In 43 patients with a non-restrictive pattern, a SFpvf <40% was identified, while in 21 patients with a restrictive mitral flow pattern the SFpvf was >40%. Of the 366 patients, 176 (48%) had 1 criterion for identifying a PWP>18 mm Hg. A cardiac index <2.2 l/min/m2 was measured in 190/366 (52%) patients. An inferior vena cava with a diameter <1.2 cm and an index of inferior vena cava collapse <40% was recorded in 62/366 (17%) and 80/366 (22%) patients, respectively. Two criteria for identifying RAP >5 mm Hg were present in 48/366 (13%) of patients.
3.4. Clinical and echo-Doppler accuracy
The accuracy of clinical and echo-Doppler findings in identifying hemodynamic profiles of CHF patients is reported in Table 3. The echocardiographic variables were more accurate than the clinical variables in estimating different hemodynamic indices. When applied to individual patients, the echo-Doppler assessment was also more accurate than the clinical examination 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); and dry/warm (88% vs. 51% p<0.0001) (Table 4).
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3.5. Therapy titration according to clinical, hemodynamic and echo-Doppler findings
Decision-making based on echo-Doppler and hemodynamic variables allowed better therapeutic optimization (in terms of frequency and dose) than that based on clinical findings (Table 5). There were no differences in terms of therapy management between the echo-Doppler and hemodynamic guided decision-making groups (Table 5).
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4. Discussion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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We compared the accuracy of echo-Doppler with that of clinical evaluation in assessing the hemodynamic profile of CHF patients. Furthermore, we analyzed therapeutic changes guided by echo-Doppler findings. This study shows that echo-Doppler hemodynamic measurements are more accurate than clinical evaluation in assessing the hemodynamic profile of CHF patients, providing information similar to that provided by right heart catheterization and influencing therapeutic management.
4.1. Hemodynamic profile monitoring in chronic heart failure
The role of hemodynamic variables as surrogate end-points is controversial [10]. Certainly, hemodynamic status describes the severity of the illness. Although analysis of baseline hemodynamic status in the FIRST study was not predictive of outcome, its determination is the first step in classifying CHF patients and in guiding recommended treatment approaches [3]. Furthermore, hemodynamic changes have been used to guide unloading therapy and have been shown to have prognostic significance [11,12].
The relationship between serial hemodynamic changes and outcome after drug titrations has not been investigated. However, mitral flow pattern changes that approximate those of the left ventricular filling pressure, may be a useful tool for therapy management and be strongly related to outcome [13,14]. Recent uncontrolled studies have shown that an implantable hemodynamic monitoring device may provide continuous individual hemodynamic monitoring with important implications for the management of CHF patients [15,16]. These considerations point to the emerging role of hemodynamic indices in managing patients with chronic heart failure, but above all, once again highlight how defining a patient's hemodynamic status can assist decisions concerning indications, therapy titration and outcomes [17].
In our experience, clinical assessment as a marker of hemodynamic status has a degree of uncertainty and lack of accuracy which limits its use in therapeutic decision making. Indeed, clinical examination correctly classified hemodynamic status in only 99/366 (27%) patients in our study. In contrast, echo-Doppler classified hemodynamic status correctly in 300/366 (82%) patients. This accuracy of echo-Doppler facilitates the same level of therapy optimization as that achieved using hemodynamic information. However, serial determinations of central hemodynamics to evaluate clinical status and therapeutic response are expensive and are associated with risks that preclude this technique from routine clinical practice. In contrast, echo-Doppler is a non-invasive, accurate and non-expensive tool that allows patients to be monitored in a variety of different settings.
4.2. Clinical implications
Echo-Doppler could play an important new role in managing the care of CHF patients. It is possible to identify different scenarios in which hemodynamic echo-Doppler monitoring could be used to guide clinical practice. In patients on oral therapy, baseline and/or hemodynamic changes induced by unloading maneuvers may identify subgroups of patients with different tolerance to therapy or different risk of events [18]. Many patients with clinical evidence of a "wet" hemodynamic profile are treated with infusions of diuretics. In this intensive care setting, therapeutic options such as nitroprusside can also be used. Baseline evaluation and hemodynamic responses monitored by echo-Doppler could provide important information about drug dosages, oral unloading therapy and short-term prognosis. The management of this phase of CHF is driven by clinical information. If diuresis is poor or patients develop symptomatic hypotension and/or renal failure or have comorbid conditions (infections, chronic pulmonary disease), echo-Doppler monitoring may illustrate the discrepancy between the clinical findings and hemodynamic status. Moreover, echo-Doppler monitoring could verify responses to changes in therapy. In this scenario, echo-Doppler hemodynamic monitoring could help to optimize the timing of intravenous therapy weaning. If the clinical evidence of "wet" CHF is ambiguous, hemodynamic echo-Doppler monitoring could be useful for confirming the "wet" status, for defining therapeutic strategies and monitoring response and for preventing symptomatic hypotension and renal failure. In these patients, inotropic support can be given. Often the therapeutic choice is empirical. Echo-Doppler monitoring could also provide useful information on the hemodynamic impact and effect on mitral valve regurgitation, consequent to inotropic support.
In "dry" patients, hemodynamic echo-Doppler monitoring could identify cardiac reserve exhaustion or iatrogenic hypovolemia, which require different treatment strategies. All of the above information aids clinical decision-making in CHF patients. In this perspective, echo-Doppler is not a rival or an alternative to clinical evaluation, but provides supplementary data for correct evaluation of the patients condition and for optimising therapeutic decisions. Clinical signs, such as a third heart sound and/or elevated jugular venous pressure, can provide prognostic information [19]. However, the ability to hear a third heart sound and the inter-observer agreement in identifying these clinical signs is moderate to low [20]. Echo-Doppler measured hemodynamic equivalents of these signs could help the physician to classify CHF patients into homogeneous hemodynamic groups in order to choose the appropriate management algorithm. Furthermore, compared to right heart catheterization, echo-Doppler assessment is cheaper and safer for the patient but yields the same information.
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5. Study limitations |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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The greatest limitation of this study is that the results cannot be applied to patients with atrial arrhythmias, a pacemaker and/or a prosthetic mitral valve. Our patients were young and with chronic heart failure; thus, these findings cannot be automatically transferred to patients with diastolic heart failure, acute heart failure or elderly patients with CHF. Although echocardiographic measurements can be affected by poor image quality or by inter-observer variability, using a cut-off value of reproducibility to evaluate a result as significant minimized the likelihood of these errors occurring. Echo-Doppler variables may be affected by acute dyspnea and/or exaggerated tachycardia. The clinical and instrumental (echo-Doppler, hemodynamic) decisions were made by different physicians, which could explain the different therapy regimens.
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6. Conclusions |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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We believe that echo-Doppler hemodynamic monitoring at baseline, during loading manipulations or when there is uncertainty in decision-making, is useful for managing optimized therapy in patients with CHF and for redefining therapeutic strategies, including heart transplantation.
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Acknowledgments |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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I would like to dedicate this manuscript to my father Domenico, who recently died, whose affection, support and tolerance have been determinants in the maturity of my person.
Grazie Papà.
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References |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. Study limitations6. ConclusionsAcknowledgmentsReferences |
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