Practice Update: Cardiology

EDITOR’S PICKS 6

Ambulatory hemodynamic monitoring reduces heart failure hospitalizations in “real-world” clinical practice JACC: Journal of the American College of Cardiology Take-home message

in analyses restricted to 6-month survivors. Sim- ilar reductions in HFH and costs were noted in the subset of 480 patients with complete data available for 12 months before and after implan- tation (HR: 0.66; 95% CI: 0.57 to 0.76; p < 0.001). CONCLUSIONS As in clinical trials, use of ambula- tory hemodynamic monitoring in clinical practice is associated with lower HFH and comprehen- sive HF costs. These benefits are sustained to 1 year and support the “real-world” effectiveness of this approach to HF management. Ambulatory hemodynamic monitoring reduces heart failure hospitalizations in “real-world” clinical practice. J Am Coll Cardiol 2017 May 16;69(19)2357-2365, AS Desai, A Bhimaraj, R Bharmi, et al. Associate Chief–Clinical Affairs, Cardiovascular Division of Medicine, as well as Medical Director of the Heart and Vascular Center at Penn Medicine in Philadelphia. COMMENT By Mariell L Jessup MD, FACC, FAHA, FESC T he CHAMPION trial, published in 2011, reported a 37% reduction in heart failure-related hospitaliza- tions in NYHA class III patients implanted with a pulmonary artery pressure mon- itor compared with a control group. There were many skeptics; the FDA delayed approval for several years. Thus, the current study examining a retrospective cohort of 1114 Medicare patients receiving the same hemo- dynamic monitor is now reported as representative of a real-world practice. The investigators noted a 45% lower rate of cumulative heart failure–related hospitalizations compared with a similar period before implantation, with a corre- sponding heart failure cost reduction of US$7433 per patient. Nonetheless, the accompanying editorial by Krumholz and Dhruva suggests residual skep- ticism about the magnitude of effect attributed to the device alone. Clearly, more real-world evidence is needed. Dr Jessup is Professor of Medicine at the Perelman School of Medicine, University of Pennsylvania, and

• In this retrospective study, data from 1114 patients undergoing pulmonary artery pressure sensor implantation were evaluated to examine the effectiveness of ambulatory hemodynamic monitoring in reducing heart failure hospitalization. Of these patients, 1020 heart failure hospitalizations occurred before device implan- tation compared with 381 hospitalizations, 139 deaths, and 17 device implantations and/or transplants in the 6 months following implantation. This decreased rate of heart failure hospitalizations was associated with a 6-month cost reduction of US$7433 per patient. • These data support the real-world effectiveness of the use of ambulatory hemodynamic monitoring in clinical practice.

Abstract BACKGROUND In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Associ- ation [NYHA] Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lower in patients managed with guid- ance from an implantable pulmonary artery pressure sensor compared with usual care. OBJECTIVES This study examined the effective- ness of ambulatory hemodynamic monitoring in reducing HFH outside of the clinical trial setting. METHODS We conducted a retrospective cohort study using U.S. Medicare claims data from patients undergoing pulmonary artery pressure sensor implantation between June 1, 2014, and December 31, 2015. Rates of HFH during pre- defined periods before and after implantation

were compared using the Andersen-Gill extension to the Cox proportional hazards model while accounting for the competing risk of death, ventricular assist device implantation, or cardiac transplantation. Comprehensive heart failure (HF)-related costs were compared over the same periods. RESULTS Among 1,114 patients receiving implants, there were 1,020 HFHs in the 6 months before, compared with 381 HFHs, 139 deaths, and 17 ventricular assist device implantations and/or transplants in the 6 months after implantation (hazard ratio [HR]: 0.55; 95% confidence inter- val [CI]: 0.49 to 0.61; p < 0.001). This lower rate of HFH was associated with a 6-month com- prehensive HF cost reduction of $7,433 per patient (IQR: $7,000 to $7,884), and was robust

PRACTICEUPDATE CARDIOLOGY