Noninvasive hemodynamic monitoring in emergency patients with suspected heart failure, sepsis and stroke: the PREMIUM registry

Richard M Nowak, Prabath Nanayakkara, Salvatore DiSomma, Phillip Levy, Edmée Schrijver, Rebecca Huyghe, Alessandro Autunno, Robert L Sherwin, George Divine, Michele Moyer, Richard M Nowak, Prabath Nanayakkara, Salvatore DiSomma, Phillip Levy, Edmée Schrijver, Rebecca Huyghe, Alessandro Autunno, Robert L Sherwin, George Divine, Michele Moyer

Abstract

Introduction: Noninvasive hemodynamic (HD) assessments in the emergency department (ED) might assist in the diagnosis, therapeutic plan development and risk stratification of acutely ill patients. This multinational observational study was designed to initiate noninvasive HD measurements prior to any ED patient therapeutic interventions and broadly evaluate them for potential diagnostic, therapeutic and predictive value.

Methods: We enrolled patients with suspected acute heart failure (AHF), sepsis or stroke. Continuous noninvasive HD monitoring was begun using the Nexfin finger cuff device (Edwards LifeSciences, BMEYE, Amsterdam, Netherlands). Beat-to-beat HD measurements were averaged for the initial 15 minutes, prior to therapeutic intervention. We performed suspected disease group comparisons and evaluated HD predictors of 30-day mortality.

Results: Of 510 patients enrolled: 185 (36%) AHF, 194 (38%) sepsis and 131 (26%) stroke. HD variables were significantly different (p<0.05) amongst the groups. Cardiac output and index and stroke volume index (SVI) were highest in sepsis (6.5, 3.5, 36), followed by stroke (5.5, 2.7, 35.8), and lowest in AHF (5.4, 2.7, 33.6). The in-group HD standard deviations and ranges measurements were large, indicating heterogeneous underlying HD profiles. Presenting SVI predicted 30-day mortality for all groups.

Conclusion: Presenting ED noninvasive HD data has not been previously reported in any large patient population. Our data suggest a potential role for early noninvasive HD assessments aiding in diagnosing of patients, individualizing therapy based on each person's unique HD values and predicting 30-day mortality. Further studies and analyses are needed to determine how HD assessments should be best used in the ED.

Figures

Figure 1
Figure 1
Nexfin continuous hemodynamic recording. Nexfin continuous HD recording in a non-sedated, non-intubated patient showing beat to beat variability. Averaging the first 15 minutes (shaded area) smooths out these variations.
Figure 2
Figure 2
Stroke volume index receiver operating curves for 30-day mortality. A, acute heart failure; B, sepsis; C, stroke; AUC, area under curve

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