Elsevier

Journal of Cardiac Failure

Volume 27, Issue 10, October 2021, Pages 1045-1052
Journal of Cardiac Failure

Aortic Pulsatility Index: A Novel Hemodynamic Variable for Evaluation of Decompensated Heart Failure

https://doi.org/10.1016/j.cardfail.2021.05.010Get rights and content

Highlights

  • Heart failure is a progressive disease, but invasive hemodynamic measurements have shown only modest correlation with clinical outcomes.

  • The aortic pulsatility index is a novel metric to assess the severity of illness in a patient with heart failure.

  • An aortic pulsatility index of less than 1.45 was associated with a need for the continuous use of vasoactive medications or temporary mechanical circulatory support devices, implantation of a left ventricular assist device, heart transplantation, or death within 30 days.

  • The aortic pulsatility index is a novel invasive hemodynamic measurement that is independently associated with freedom from advanced therapies or death at the 30-day follow-up.

Abstract

Background

Right heart catheterization for invasive hemodynamics has shown only modest correlation with clinical outcomes. We designed a novel hemodynamic variable that incorporates ventricular output and filling pressure. We anticipated that the aortic pulsatility index (API) would correlate with clinical outcomes in patients with heart failure.

Methods and Results

We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (February 2013 to November 2019). The API was calculated as (systolic blood pressure – diastolic blood pressure)/pulmonary capillary wedge pressure. The primary outcome was freedom from advanced therapies, defined as the need for inotropes, temporary mechanical circulatory support, a left ventricular assist device, or orthotopic heart transplantation, or death at 30 days. A total of 224 patient encounters, age 57 years (48–66 years; 34% women; 31% ischemic cardiomyopathy) were included. In univariable analysis, lower baseline API was significantly associated with progression to advanced therapies or death at 30-days (odds ratio 0.43, 95% confidence interval 0.30–0.61; P < .001) compared with those on continued medical management. Receiver operator characteristic analysis specified an optimal cutpoint of 1.45 for API. A Kaplan–Meier analysis indicated an association of API with the primary outcome (79% for API ≥ 1.45 vs 48% for API < 1.45). In multivariable analysis, higher API was strongly associated with freedom from advanced therapies or death (odds ratio 0.38, 95% confidence interval 0.22–0.65, P ≤ .001), even when adjusted for baseline characteristics and routine right heart catheterization measurements.

Conclusions

The API is a novel invasive hemodynamic measurement that is associated independently with freedom from advanced therapies or death at 30-day follow-up.

Section snippets

Methods

This study was approved by the University of Chicago Institutional Review Board. Retrospective data were collected on consecutive patients undergoing RHC at the University of Chicago between January 2013 and November 2019. Patients were retrieved with a coding query via the electronic medical record (Epic 2018, Epic Headquarters, Verona, WI). Included patients had to be 18 years or older and undergoing a milrinone drug study completed by a member of the advanced heart failure team to assess

Baseline

A total of 224 procedures were analyzed from 224 individual patients. At the time of procedure, average age was 57 years (48–66 years), and 33.5% were women, 39.3% Caucasian, and 31.3% had underlying ischemic cardiomyopathy. Patients with continued medical management were more likely to have had a history of stroke at baseline (20.3% vs 8.7%, P = .01). Additional data regarding baseline characteristics and medical regimens can be seen in Table 1. Moderate sedation was used in 103 procedures

Discussion

In this study, we introduce and derive the API, a novel hemodynamic measurement in patients with acute, chronic, and worsening heart failure, which is significantly associated with adverse clinical outcomes. API is associated with advanced therapies or death at 30 days with a reasonable degree of sensitivity and specificity.

The API was designed to simultaneously represent cardiac function and filling pressures. It accomplishes this goal in 2 ways: (1) by clinical intuition, because medical

Limitations

This study is limited by its retrospective nature. Additionally, all RHC evaluations were done by a single group of physicians, which limits interoperator variability, and may decrease the applicability to patients not evaluated in our center. Likewise, a statistical limitation is that the sample size did not provide the ability to validate the ROC cutoff points by splitting the dataset into training and testing datasets; future research would require the testing these cutoff points with new

Conclusions

The API is a novel invasive hemodynamic measurement that is independently associated freedom from advanced therapies or death at 30-day follow-up.

LAY SUMMARY

  • The API is a novel metric to assess the severity of illness in a patient heart failure.

  • In patients with heart failure, with an API of less than 1.45 was associated with implantation of a left ventricular assist device, heart transplantation, the need for continuous use of vasoactive medications, or temporary mechanical circulatory support

Disclosures

The authors disclose no conflicts.

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