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Pulmonary Artery Catheter Use and Mortality in the CICU
Quick Takes
- Pulmonary artery catheter (PAC) use in contemporary cardiac intensive care units (CICUs) is common based on this registry analysis (20.0% of all CICU admissions, 45.8% of admissions with shock).
- PAC use is influenced by patient-level factors (such as mechanical circulatory support use, primary diagnosis of HF) as well as center-specific practice patterns.
- PAC use for patients with shock in the CICU is associated with lower in-hospital mortality compared to no PAC use.
Study Questions:
In contemporary cardiac intensive care units (CICUs), what is the current use of pulmonary artery catheters (PACs), what center- and patient-level factors influence use, and how is use associated with in-hospital mortality?
Methods:
This study utilized the multicenter Critical Care Cardiology Trials Network registry of patients admitted to American Heart Association level 1 CICUs. The study period for this analysis was September 2017 to September 2021. During this period, participating centers annually submitted clinical data on consecutive patients admitted during a 2-month reporting window. Patients admitted for postsurgical recovery or as overflow from the medical intensive care unit (ICU) were excluded.
Results:
There were 13,618 total CICU admissions at 34 participating sites. Of these, 3,827 admissions (28.1%) were for shock and 2,583 (19.0%) for cardiogenic shock (CS). In the overall CICU population, the median age was 66.0 years (interquartile range, 56.0-76.0 years), 37.0% were female, and 31.0% were non-White. Primary admitting diagnoses included acute coronary syndrome (29.4%), heart failure (HF) (15.7%), and valvular heart disease (VHD) (7.8%). For patients with shock and CS, mechanical circulatory support (MCS) use was common at 28.4% and 36.9%, respectively. In-hospital mortality for all CICU admissions and admissions with shock were 12.1% and 32.0%, respectively.
In the overall CICU population, PACs were used in 2,719 admissions (20.0%). Use increased in cases of shock (45.8%) and CS (55.6%). After multivariable analysis, the two strongest patient-level factors independently associated with PAC use in the overall CICU population were needed for MCS (odds ratio [OR], 5.99; 95% confidence interval [CI], 5.15-6.98, p < 0.001) and a primary diagnosis of HF (OR, 3.33; 95% CI, 2.91-3.81; p < 0.001). Other patient-level factors included shock/hypotension, higher inotrope/vasopressor use, history of HF, pulmonary hypertension, severe VHD, alanine transaminase level, male sex, younger age, and lower lactate levels. On a center level, use of PACs in the overall CICU population ranged from 1-35%, and in cases of shock, from 8-73%. PAC compared to no PAC use in patients with shock was associated with a lower mortality rate (28.4% vs. 35.0%; adjusted OR, 0.79; 95% CI, 0.66-0.96; p = 0.017).
Conclusions:
PAC use in contemporary CICUs is common, influenced by patient-level factors (MCS use, primary diagnosis of HF), varies significantly by center, and is associated with lower in-hospital mortality for patients with shock compared to no PAC use.
Perspective:
The use of PACs in ICUs has evolved over the years, with notable declines after earlier evidence suggested lack of benefit in a broader population with a signal for harm. However, PACs remain an important diagnostic and management tool, and ongoing debate exists regarding the optimal patient population that would benefit from its use. Current HF guidelines recommend that in select patients with HF and persistent/worsening clinical course or uncertain hemodynamics, invasive hemodynamic monitoring can be useful (Class 2a recommendation). This study highlights that PAC use is still common in CICUs despite lack of clear data, and significant variability exists between centers. Importantly, PAC use in cases of shock in the CICU appears to have an important role in possibly improving outcomes, though future randomized trials would help provide a more definitive answer. Important limitations of this study include the observational nature of the dataset, potential lack of generalizability (may not represent all CICUs nationally), limited data collection window of 2 months annually, and lack of granular data on management changes in response to invasive hemodynamics.
Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Vascular Medicine, Acute Heart Failure, Pulmonary Hypertension, Hypertension
Keywords: Acute Coronary Syndrome, Alanine Transaminase, Cardiac Catheters, Catheters, Critical Care, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Hypotension, Intensive Care Units, Pulmonary Artery, Shock, Shock, Cardiogenic
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