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Pulmonary Artery Catheter Adds Little in Heart Failure Management

Insights come from the ESCAPE trial and its 433 subjects with severe, symptomatic heart failure despite standard treatment.

Is heart failure (HF) therapy improved when guided by pulmonary-artery catheter (PAC) monitoring? Researchers at 26 centers in North America conducted the ESCAPE trial to answer this question. They randomized 433 patients with severe, symptomatic HF despite standard treatment to receive either PAC-guided therapy or therapy guided by clinical findings. The study protocol established right-atrial and pulmonary-capillary wedge pressure treatment goals but not specific drug recommendations.

Improvements in symptoms, jugular venous pressure, and edema were significant — and similar — in the two groups. The groups also had similar rates of out-of-hospital days alive at 6 months (the primary endpoint) and of 30-day survival and length of hospitalization. Compared with the clinical assessment group, the PAC-guided group had trends toward improvement in exercise and quality-of-life endpoints but also had more in-hospital infections. No subgroup (e.g., those stratified by vasodilator and inotrope use) had a significant advantage or disadvantage with PAC-guided therapy.

In a separately published meta-analysis of 13 randomized controlled trials (including ESCAPE), PAC-guided management had no advantage over non–PAC-guided management in survival or length of hospitalization among 5051 critically ill patients.

Comment: PAC-guided therapy should not be used routinely for managing heart failure patients. Certain high-risk subgroups might benefit from such an approach, but further study is needed to identify them. We also must identify therapeutic goals for management and additional therapeutic options for HF patients.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology October 28, 2005

Citation(s):

The ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: The ESCAPE trial. JAMA 2005 Oct 5; 294:1625-33.

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• Medline abstract (Free)

Shah MR et al. Impact of the pulmonary artery catheter in critically ill patients: Meta-analysis of randomized clinical trials. JAMA 2005 Oct 5; 294:1664-70.

• Original article (Subscription may be required)
• Medline abstract (Free)

Hall JB. Searching for evidence to support pulmonary artery catheter use in critically ill patients. JAMA 2005 Oct 5; 294:1693-4.

• Original article (Subscription may be required)
• Medline abstract (Free)