The Invisible Silent Killer
2021; Elsevier BV; Volume: 96; Issue: 8 Linguagem: Inglês
10.1016/j.mayocp.2021.06.015
ISSN1942-5546
Autores Tópico(s)Pulmonary Hypertension Research and Treatments
ResumoSystemic hypertension has been described as a “silent killer” due to its asymptomatic course which can remain unnoticed by clinicians even as it gives rise to coronary artery disease, stroke, and renal failure. That said, if one is looking for hypertension, it can be easily found in the first set of data collected routinely during any patient encounter. In moving from the systemic to the pulmonary circulation, however, elevated blood pressures pose a formidable mortality risk that is not only silent but also nearly invisible. It is impossible to “see” pulmonary hypertension with a sphygmomanometer purchased at the local drug store. Perhaps the best opportunity to unmask this disease occurs at the time of coronary angiography when the information can be obtained directly by performing a right heart catheterization. Patel et al1Patel N. Narasimhan B. Bandyopadhyaym D. et al.Impact of pulmonary hypertension on in-hospital outcomes and 30-day readmissions following percutaneous coronary interventions.Mayo Clin Proc. 2021; 96Abstract Full Text Full Text PDF Scopus (1) Google Scholar introduce us to some compelling reasons to diagnose pulmonary hypertension at the time of percutaneous coronary intervention (PCI) in their article “Impact of Pulmonary Hypertension on In-hospital Outcomes and 30-day Readmissions Following Percutaneous Coronary Interventions.” Patients with pulmonary hypertension are more likely to suffer an adverse outcome at just about every step in their clinical trajectory after PCI. Those who survive to hospital discharge are far more likely to be readmitted within 30 days, frequently in the setting of a heart failure exacerbation. Of course, recognizing pulmonary hypertension only matters if you have treatments to offer which can favorably impact the course of the disease. This is where the story from the National Readmissions Database gets even more interesting. The 628 patients with pulmonary hypertension who died in the hospital after PCI followed a clinical course that is both predictable and preventable in patients with this disease. It is important to understand how the 3.2% of PCI patients with pulmonary hypertension were identified in this study. Although it seems reasonable to assume that a right heart catheterization may have been performed in a significant percentage of them, these data are not available. Instead, the authors relied on International Classification of Diseases, Ninth Revision (ICD-9) codes 416.0 and 416.8 to distinguish between the two groups. It should be readily apparent that a complete hemodynamic assessment at the time of PCI provides considerably more valuable information than the presence of an ICD-9 code alone. Whether the collection of this type of data influences clinical outcomes is a subject of some debate.2Sandham J.D. Hull R.D. Brant R.F. et al.A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.N Engl J Med. 2003; 348: 5-14Crossref PubMed Scopus (1122) Google Scholar Nevertheless, we should be careful not to confuse the utility provided by the Swan Ganz catheter and the ability of a given provider to correctly act upon the data that are rendered.3Tukey M.H. Wiener R.S. The current state of fellowship training in pulmonary artery catheter placement and data interpretation: a national survey of pulmonary and critical care fellowship program directors.J Crit Care. 2013; 28: 857-861Crossref PubMed Scopus (7) Google Scholar It should come as no surprise that practice patterns vary considerably among proceduralists at the time of coronary angiography. In one study that reviewed 1282 coronary angiography procedures performed at two large community hospitals, a right heart catheterization was performed 52% of the time.4Malone M.L. Bajwa T.K. Battiola R.J. et al.Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography.Cathet Cardiovasc Diagn. 1996; 37: 125-130Crossref PubMed Scopus (4) Google Scholar But even after controlling for patient characteristics, practice variation between the 37 individual cardiologists ranged from 10% to 90%.4Malone M.L. Bajwa T.K. Battiola R.J. et al.Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography.Cathet Cardiovasc Diagn. 1996; 37: 125-130Crossref PubMed Scopus (4) Google Scholar Suffice it to say that an understanding of cardiac power output, filling pressures, and pulmonary artery pulsatility index (PAPi) offers the first step toward a better outcome to the provider who knows how to use these data. Based on the adverse events reported in the pulmonary hypertension group, it seems reasonable to assume that right heart catheterization data were either not collected or improperly acted upon in the present study. For instance, although cardiogenic shock was diagnosed in 1128 patients, only 53 of them were placed on mechanical circulatory support (MCS) with 41 patients receiving a left ventricular assist device and 12 patients supported on extracorporeal membrane oxygenation. According to the findings of the Detroit Shock Initiative (where right heart catheterization use was only 84% despite being a requirement of the protocol), early initiation of MCS as directed by hemodynamic monitoring has the potential to dramatically improve survival in this clinical scenario.5Basir M.B. Schreiber T. Dixon S. et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (114) Google Scholar Interestingly, the scrutiny which was apparently applied to the use of MCS in these patients did not extend to the initiation hemodialysis. A full 20.6% of pulmonary hypertension patients in this study experienced acute kidney injury with 2210 patients requiring renal replacement therapy. It is unclear whether this decision was made only after optimizing support of the right ventricle (RV). It is possible that the 341 patients with a “vasopressor requirement” were managed with inotropes, but if the real world is any guide, we would not be surprised to find that Levophed was the most common vasoactive medication in the medication administration record. Perhaps the popularity of this drug can be explained by the fact that it is easy to identify systemic hypotension in the electronic medical record (EMR). In many cases, low blood pressure values are represented in highlighted red text. In contrast, even in the cases where pulmonary artery catheter data are available, the values that depict RV failure are often hidden from site. Pulmonary artery pulsatility index is arguably the most accurate way to assess RV dysfunction, but it can only be obtained by performing a calculation using the data that are available in the EMR.6Kochav S.M. Flores R.J. Truby L.K. Topkara V.K. Prognostic impact of pulmonary artery pulsatility index (PAPi) in patients with advanced heart failure: insights from the ESCAPE trial.J Card Fail. 2018; 24: 453-459Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Therefore, improving the ease with which clinicians can identify RV failure represents a second opportunity for better management of pulmonary hypertension after PCI. For patients who undergo right heart catheterization at the time of PCI and are found to have a PAPi of less than 0.9, strong consideration should be given to the use of a percutaneous RV assist device. In our experience, this strategy has the potential to liberate the patient from mechanical ventilation, facilitate early ambulation, preserve renal function, and eliminate the need for vasoactive medications.7Badu B. Cain M.T. Durham L.A. et al.A dual-lumen percutaneous cannula for managing refractory right ventricular failure.ASAIO J. 2020; 66: 915-921Crossref PubMed Scopus (10) Google Scholar Despite the authors’ efforts to exclude heart failure patients from the analysis, 20% of the patients in the pulmonary hypertension group experienced a 30-day readmission for heart failure. The availability of implantable hemodynamic monitoring systems suggests an opportunity to improve the visibility of pulmonary hypertension even after hospital discharge.8Abraham W.T. Adamson P.B. Bourge R.C. et al.Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial.Lancet. 2011; 377: 658-666Abstract Full Text Full Text PDF PubMed Scopus (915) Google Scholar In an effort to apply the findings of the present study to everyday clinical practice, I would like to propose three practical suggestions which have the potential to improve the visibility of pulmonary hypertension in our patient population and prevent the adverse events which often occur following PCI. First, although it is common to include a presentation of laboratory data such as creatinine and international normalized ratio as part of the pre-catheterization time-out procedure, I would advocate for an additional discussion on the role for a right heart catheterization based on the available data with respect to RV systolic pressure and ventricular function. Second, providers should advocate for their hospital’s information technology department to include PAPi along with the existing hemodynamic parameters which are easily observable in the EMR. Finally, at least one proceduralist in every catheterization lab should be trained in the placement of percutaneous RV support so that unfamiliarity with this tool does not result in a bias toward less effective treatment strategies. Implementing these types of initiatives has the potential for bringing the adverse consequences of pulmonary hypertension into clear view. Impact of Pulmonary Hypertension on In-Hospital Outcomes and 30-Day Readmissions Following Percutaneous Coronary InterventionsMayo Clinic ProceedingsVol. 96Issue 8PreviewTo evaluate the impact of pulmonary hypertension (PH) on percutaneous coronary intervention (PCI) outcomes and 30-day all-cause readmissions by analyzing a national database. Full-Text PDF
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