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HOMEOSTASIS: Physician-directed self-management associated with improved outcomes, hemodynamics

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Patients using physician-directed self-management of their left atrial pressure showed the potential to improve symptoms, hemodynamics and outcomes in the setting of advanced HF, study results suggested.

Researchers for the HOMEOSTASIS trial enrolled 40 patients with reduced or preserved left ventricular ejection fraction, acute decompensation and a history of NYHA Class III or IV HF. Patients were implanted with a left atrial pressure monitor, and results were reported twice daily. Patients and physicians were blinded to these results for the first three months of the study. Following unblinding, individualized instructions guided by the recorded atrial pressures were given to each patient. The researchers sought to determine event-free survival during a median follow-up of 25 months, and the study endpoint was clinical and neurological.

According to the results, survival was 61% at three years, with a decreased frequency in events reported after the first three months (HR=0.16; 95% CI, 0.04-0.68). The frequency of readings >25 mm Hg was decreased by 67% during the guided therapy (P<.001). Mean daily left atrial pressure decreased from 17.6 mm Hg (95% CI, 15.8-19.4) to 14.8 mm Hg (95% CI, 13.0-16.6) during the first three months of pressure-guided therapy. The frequency of left atrial pressure readings >20 mm Hg also decreased by 59% vs. the observation period (P<.001). The researchers also reported improvements in NYHA functional class (–0.7 ± 0.8; P<.001) and LVEF (7 ± 10%; P<.001). Doses of ACE inhibitors, angiotensin receptor antagonists and beta-blockers (P<.001 for all) were uptitrated, and doses of loop diuretics decreased.

“In this small observational study, physician-directed patient self-management of HF with direct left atrial pressure monitoring was associated with improved left atrial pressure control, reduced symptoms, more optimal neurohormonal antagonist and diuretic dosing and a reduction of early clinical events,” the researchers concluded.

“The present data indicate that hemodynamic decompensation nearly always precedes clinical decompensation and suggest that outpatient hemodynamic monitoring linked to a self-management therapeutic strategy could change current management of advanced HF and potentially facilitate more optimal therapy and improved outcomes.”

Ritzema J. Circulation. 2010;121:1086-1095.

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