Balloon-floating right heart catheter monitoring for acute coronary syndromes complicated by heart failure - Discordance between guidelines and reality

Purpose: Current guidelines (class IIA recommendations) recommend balloon-floating right heart catheter monitoring (RHC) in particular for patients with ST elevation acute coronary syndromes (ACS) who have progressive heart failure (HF) or cardiogenic shock (CS), as well as for other ACS patients with hemodynamic instability. However, their implementation remains undetermined. The aim of the study was to analyze RHC use in ACS patients, in particular those with HF. Subjects and Methods: The Euro Heart ACS Survey enrolled 10,484 ACS patients (ST elevation, no ST elevation and undetermined ECG). We analyzed the general RHC use, in particular in HF patients. Results: Of the 10,234 patients with data regarding RHC use, RHC was used in 309 patients (3.0%). Patients with RHC presented more often with ST segment elevation ACS, symptoms other than angina, Killip class III/IV, lower systolic blood pressure and a higher heart rate. Of the 10,136 patients with documented HF status, 549 (5.4%) had CS, 2,529 (25.0%) had mild to moderate HF, and 7,058 (69.6%) had no HF. RHC was performed in 111 (20.2%) patients with CS, 87 (3.4%) patients with mild to moderate HF, and 109 (1.5%) patients without HF. In contrast, echocardiography was performed in 376 (68.4%) CS patients, 1,812 (71.6%) patients with mild to moderate HF, and 4,484 (63.5%) patients without HF. Conclusions: In contrast to the unequivocal recommendations to use RHC for hemodynamically unstable ACS patients, RHC is infrequently used in current clinical practice. Perhaps it has been supplanted by echocardiography, a noninvasive and readily available modality. Given the reserved use of RHC in ACS patients, and the reported complications associated with RHC, the guidelines regarding its use should be reconsidered.