Is Ambulatory Hemodynamic Monitoring Beneficial to Patients With Advanced Heart Failure?

Abstract

Patients with advanced heart failure (aHF) exhibit persistent severe symptoms despite optimal guidelinedirected medical therapy, including pharmacologic and cardiac resynchronization therapy (CRT), as indicated and tolerated. Although CRT is a highly effective treatment for drugrefractory heart failure (HF) with reduced ejection fraction (HFrEF), the longterm mortality of these patients is not negligible.1 The care of this “vulnerable” group of patients requires collaborative efforts by HF and electrophysiology teams.2 More important, ≈30% of recipients do not benefit from CRT, although this percentage varies depending on the definition of nonresponse.3 Nonresponse to CRT is a challenging healthcare issue, and some of these patients who are lacking left ventricular remodeling and symptomatic improvement will progress to aHF and may require aHF therapies.3 Optimization of pharmacological therapies and close monitoring to prevent HF readmissions and detect early progression to aHF are key elements in chronic disease management of these patients. An earlier post hoc analysis of patients with acute HF enrolled in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial suggested that patients with persistently elevated left ventricular filling pressures constitute a group at high risk for death, rehospitalization, or heart transplantation.4 Therefore, improving filling pressures should be an important goal in the care of patients with aHF. Moreover, invasive hemodynamic assessment may facilitate identification of suitable candidates for advanced cardiac therapies. Because hemodynamic congestion precedes clinical congestion by several weeks,5 remote hemodynamic monitoring has risen as viable and practical management strategy for selected patients with HFrEF.