Clinical meaning
Advanced HF management requires understanding of hemodynamic profiles classified by the Stevenson/Nohria 2x2 framework: warm-dry (A — compensated), warm-wet (B — congested, adequate perfusion), cold-dry (L — hypoperfused, no congestion), cold-wet (C — congested and hypoperfused). Invasive hemodynamic monitoring with a pulmonary artery catheter measures PCWP (normal < 12 mmHg, elevated in congestion), cardiac index (normal > 2.2 L/min/m², low output < 2.0), SVR (elevated in cardiogenic shock), and mixed venous O2 saturation (SvO2 < 65% indicates tissue hypoperfusion). These parameters guide pharmacological optimization: vasodilators (nitroprusside, nitroglycerin) for elevated SVR and congestion; inotropes (dobutamine, milrinone) for low output; and vasopressors (norepinephrine, vasopressin) for cardiogenic shock with severe hypotension.
Diagnosis & workup
Diagnostics & workup: - Pulmonary artery catheter: PCWP, PA pressures, cardiac index, SVR, SvO2, transpulmonary gradient - Echocardiogram: LVEF, RV function (TAPSE), mitral/tricuspid regurgitation severity - BNP/NT-proBNP trending for congestion assessment - Cardiopulmonary exercise testing (CPET): peak VO2 < 14 mL/kg/min suggests need for advanced therapies - Right heart catheterization for transplant evaluation: PVR, transpulmonary gradient, PA pulsatility index - Lab panel: renal function trending (cardiorenal syndrome), liver function (congestive hepatopathy), albumin - INTERMACS profile classification for LVAD candidacy (1-7 scale, 1 being cardiogenic shock) - HF survival models: SHFM (Seattle Heart Failure Model) for 1-5 year survival estimation