LETTER TO THE EDITOR
Hemodynamic profiles in heart failure: Reply
Anju Nohria, MD,
Sui W. Tsang, BS,
James C. Fang, MD,
Eldrin F. Lewis, MD,
John A. Jarcho, MD,
Gilbert H. Mudge, MD and
Lynne W. Stevenson, MD
Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA
lstevenson{at}partners.org
We appreciate Dr. Pressman's interest in our study regarding the bedside evaluation of hemodynamic profiles in patients hospitalized with a new or prior diagnosis of heart failure (1). Hemodynamic data are available for only 3 of 16 patients at the time of "profile L" (cold-dry) assessment, and we are therefore unable to confirm how often these patients have a low cardiac index without elevated filling pressures. The routine resting echocardiographic data in these patients demonstrate dilated left ventricles (mean LVEDD 6.2 ± 0.75 cm) with only mild-moderate mitral regurgitation. Dr. Pressman's speculation that profile L might represent some patients with a low cardiac output due to intravascular depletion provides a possible additional explanation for this profile.
However, it has been consistently shown that stroke volume is maintained at near normal filling pressures in dilated heart failure (2). The ongoing National Institutes of Health (NIH)-sponsored Evaluation Study of Congestive Heart failure and Pulmonary Artery Catheterization Effectiveness trial (ESCAPE) (3) will shed further light on the correlation between hemodynamic parameters and the clinical profiles proposed in our study.
As stated by Dr. Pressman, mitral inflow patterns on Doppler echocardiography have been shown to correlate with left-sided filling pressures (4) and to predict outcomes in patients with heart failure (5). We did not routinely assess echocardiographic mitral filling patterns at the time of admission. Therefore, we cannot comment on how our clinical classification system correlates with Doppler patterns of diastolic filling or whether clinical profiles provide additional prognostic value. Doubtless, many diagnostic parameters could be obtained to add to our clinical profiles. The intent of our investigation was to validate a simple bedside assessment to help classify patients at the time of presentation and to guide the selection of initial therapies.
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References
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1. Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:1797–1804[Abstract/Free Full Text]
2. Stevenson LW, Tillisch JH. Maintenance of cardiac output with normal filling pressures in patients with dilated heart failure. Circulation. 1986;74:1303–1308[Abstract/Free Full Text]
3. Shah MR, O'Connor CM, Sopko G, Hasselblad V, Califf RM, Stevenson LW. Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE): design and rationale. Am Heart J. 2001;141:528–535[CrossRef][Medline]
4. Yamamoto K, Nishimura RA, Chaliki HP, Appleton CP, Holmes DR Jr, Redfield MM. Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: critical role of left ventricular systolic function. J Am Coll Cardiol. 1997;30:1819–1826[Abstract]
5. Whalley GA, Doughty RN, Gamble GD, et al. Pseudonormal mitral filling pattern predicts hospital re-admission in patients with congestive heart failure. J Am Coll Cardiol. 2002;39:1787–1795[Abstract/Free Full Text]
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