Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. Ritzema and colleagues conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure. Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16, P=0.012). Mean daily left atrial pressure fell from 17.6 mm Hg in the first 3 months to 14.8 mm Hg to 16.6 mm Hg; P=0.003) during pressure-guided therapy. The frequency of elevated readings (>25 mm Hg) was reduced by 67% (P<0.001). There were improvements in New York Heart Association class (P<0.001) and left ventricular ejection fraction (P<0.001). Doses of angiotensin-converting enzyme/angiotensin-receptor blockers and beta-blockers were uptitrated by 37% (P<0.001) and 40% (P<0.001), respectively, whereas doses of loop diuretics fell by 27% (P=0.15).

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The authors concluded that physician-directed patient self-management of left atrial pressure has the potential to improve hemodynamics, symptoms, and outcomes in advanced heart failure.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: This was not really a self-management study: implants in the patients’ hearts collected the information used by physicians. Patients seemingly did nothing but receive the implants. It would have been a self-management study only if patients been taught and performed self-management skills. As it was, the patients only knew what the study was about after their participation.

J Ritzema et al. Physician-Directed Patient Self-Management of Left Atrial Pressure in Advanced Chronic Heart Failure. Circulation, February 22, 2010.