Contemporary trends, predictors, and outcomes of pulmonary artery catheter use in heart failure-related cardiogenic shock.

BACKGROUND

Pulmonary artery catheterization (PAC) has re-emerged as a hemodynamic phenotyping tool in heart failure-related cardiogenic shock (HF-CS). Contemporary national data on PAC utilization, practice patterns, and outcomes remain limited. We evaluated temporal trends, predictors, and outcomes of PAC use in HF-CS without acute coronary syndrome.

METHODS

Using the National Inpatient Sample (2016-2022), we identified adult hospitalizations with cardiogenic shock excluding acute coronary syndrome. PAC was the primary exposure. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay, and hospital charges. Survey-weighted multivariable regression evaluated predictors and outcomes. Four sensitivity analyses were performed, excluding coded coronary artery disease, mechanical circulatory support, pulmonary hypertension, and durable left ventricular assist device (LVAD) implantation or heart transplantation during the index admission.

RESULTS

Among 17,480 weighted hospitalizations (unweighted n = 3496), 2655 (15.2%) underwent PAC. Utilization more than doubled from 9.9% in 2016 to 21.3% in 2022 (P for trend <0.001). After adjustment, PAC was associated with lower in-hospital mortality (aOR 0.67, 95% CI 0.54-0.83), but longer stay (+2.4 days), higher charges (+$65,075), higher rates of acute kidney injury (aOR 1.55) and mechanical circulatory support (aOR 1.69). Strongest predictors included urban teaching status (aOR 2.69), large hospital size (aOR 1.89), HFrEF (aOR 1.45), and pulmonary hypertension (aOR 1.86). The mortality association persisted across all four sensitivity analyses, including after excluding durable LVAD/transplant patients (SA4: aOR 0.74; 95% CI 0.59-0.92; P = 0.008), with aORs ranging from 0.58 to 0.74 (all P ≤ 0.010). In subgroup analysis, PAC was independently associated with lower mortality in the HFrEF phenotype (aOR 0.80; 95% CI 0.68-0.92; P = 0.006); the HFpEF subgroup was underpowered for formal inference.

CONCLUSIONS

PAC use in HF-CS more than doubled from 2016 to 2022, remained concentrated at large urban teaching hospitals, and was independently associated with lower in-hospital mortality across four sensitivity analyses, including after excluding LVAD/transplant patients, supporting prospective evaluation of PAC-guided management in HF-CS.