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Meta-Analysis of Pulmonary Artery Pressure Monitoring in HF Trials
Quick Takes
- In a meta-analysis of three randomized controlled trials of remote pulmonary artery pressure (PAP) monitoring devices, PAP-guided management compared to standard therapy led to a 30% reduction in HF hospitalizations.
- PAP-guided management compared to standard therapy did not lead to reductions in all-cause mortality.
Study Questions:
In a meta-analysis of randomized trials, does the use of remote pulmonary artery pressure (PAP) monitoring with subsequent adjustments to medical treatment reduce the risk of heart failure hospitalizations (HFHs)?
Methods:
A systematic review was conducted to identify randomized clinical trials (RCTs) assessing the clinical benefit of remote PAP-guided management in patients with HF. The primary outcome for the meta-analysis was total HFHs. Other outcomes included urgent visits requiring intravenous (IV) diuretics, all-cause mortality, and composites of these endpoints.
Results:
Three RCTs were identified (CHAMPION, GUIDE-HF, and MONITOR-HF), which included a total of 1,898 patients. Patients enrolled were outpatient status, New York Heart Association (NYHA) functional classes II-IV, and had a HFH within 12 months or an elevated natriuretic peptide level. Of note, CHAMPION and MONITOR-HF only enrolled NYHA class III patients, and CHAMPION and GUIDE-HF were sham-controlled trials. In the overall cohort, 67.8% were men and 65.8% had an ejection fraction ≤40%. Overall, 15.6%, 81.6%, and 2.8% of patients were NYHA class II, III, and IV, respectively. Mean follow-up time was 14.7 months.
Patients managed with remote PAP monitoring devices compared to standard therapy had a reduction in total HFH (0.41 vs. 0.59 events per patient-year; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.58-0.86; p = 0.0005). PAP-guided management also led to a reduction in the composite of total HFH, urgent visits requiring IV diuretics, and all-cause mortality (0.56 vs. 0.76 events per patient-year; HR, 0.75; 95% CI, 0.61-0.91; p = 0.0037) when compared to control. No significant difference in all-cause mortality was noted (HR, 0.92; 95% CI, 0.73-1.16; p = 0.495). Effects were similar across subgroups, including across a broad range of left ventricular ejection fractions.
Conclusions:
In a meta-analysis of RCTs, PAP-guided management in patients with HF reduced HFH compared to standard therapy.
Perspective:
Data on the use of wireless or remote PAP monitors have been mixed. The CHAMPION trial helped remote PAP monitors gain Food and Drug Administration (FDA) approval for use in patients with HF and NYHA class III symptoms, though there were concerns about the differential contact between the study groups. The GUIDE-HF trial included NYHA class II-IV patients, though it was overall neutral (may have been impacted by the COVID-19 pandemic). The FDA did expand use to NYHA class II patients following this. The latest open-label MONITOR-HF trial was conducted with a European cohort and demonstrated benefit.
Given some of the previous uncertainty in clinical benefit and the publication of newer data, this meta-analysis provides timely information and additional clarity. Importantly, this analysis helps reaffirm that for select patients already on maximally tolerated guideline-directed medical therapy, but with elevated risk given elevated natriuretic peptide levels or recent HFH, remote PAP-guided management can be considered to reduce the risk of future HFHs, although it has no clear impact on all-cause mortality.
Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Diuretics, Heart Failure, Hospitalization, Natriuretic Peptide, Brain, Pulmonary Artery
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