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A Personalized Approach to the Management of Congestion in Acute Heart Failure.

ABSTRACT: Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.

SUBMITTER: Moreira GR

PROVIDER: S-EPMC10919353 | biostudies-literature | 2023

REPOSITORIES: biostudies-literature

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A Personalized Approach to the Management of Congestion in Acute Heart Failure.

Moreira Gustavo R GR Villacorta Humberto H

Heart international 20231123 2

Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and th ...[more]

PMID: 38455673

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Project description:AimCongestion is a major determinant of outcomes in acute heart failure. Its assessment is complex, making sufficient decongestive therapy a challenge. Residual congestion is frequent at discharge, increasing the risk of re-hospitalization and death. Mid-regional pro-adrenomedullin mirrors vascular integrity and may therefore be an objective marker to quantify congestion and to guide decongestive therapies in patients with acute heart failure.Methods and resultsObservational, prospective, single-centre study in unselected patients presenting with acute heart failure. This study aimed to assess adrenomedullin's association with congestion and clinical outcomes: in-hospital death, post-discharge mortality and in-hospital worsening heart failure according to RELAX-AHF-2 trial criteria. Pro-adrenomedullin was quantified at baseline and at discharge. Congestion was assessed applying clinical scores. Cox and logistic regression models with adjustment for clinical features were fitted. N = 233, median age 77 years (IQR 67, 83), 148 male (63.5%). Median pro-adrenomedullin 2.0 nmol/L (IQR 1.4, 2.9). Eight patients (3.5%) died in hospital and 100 (44.1%) experienced in-hospital worsening heart failure. After discharge, 60 patients (36.6%) died over a median follow-up of 1.92 years (95% CI: 1.76, 2.46). Pro-adrenomedullin concentrations (logarithmized) were significantly associated with congestion, both at enrolment (β = 0.36 and 0.81 depending on score, each P < 0.05) and at discharge (β = 1.12, P < 0.001). Enrolment of pro-adrenomedullin was associated with in-hospital worsening heart failure [OR 4.23 (95% CI: 1.87, 9.58), P < 0.001], and pro-adrenomedullin at discharge was associated with post-discharge death [HR 3.93 (1.86, 8.67), P < 0.001].ConclusionElevated pro-adrenomedullin is associated with in-hospital worsening heart failure and with death during follow-up in patients with acute heart failure. Further research is needed to validate this finding and to explore the ability of pro-adrenomedullin to guide decongestive treatment.

Project description:BackgroundThe phase angle (PhA) in bioelectrical impedance analysis (BIA) reflects the cell membrane integrity or body fluid equilibrium. We examined how the PhA aligns with previously known markers of acute heart failure (HF) and assessed its value as a screening tool.MethodsPhA was measured in 50 patients with HF and 20 non-HF controls along with the edema index (EI), another BIA parameter suggestive of edema. Chest computed tomography-measured lung fluid content (LFC) was used to assess pulmonary congestion. A correlation analysis was conducted to evaluate the relationships between PhA and EI, NT-proBNP, and LFC. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off values for PhA and EI for classifying patients with HF. The area under the curve (AUC) was compared using the DeLong test to evaluate the performance of PhA and EI compared to that of LFC in correctly classifying HF.ResultsThe PhA levels were significantly lower in the HF group. Whole-body PhA was 4.49° in the HF group and 5.68° in the control group. Moderate and significant correlation was observed between PhA measured at 50-kHz and both NT-proBNP (-0.56 to -0.27, all p-values<0.05) and LFC (-0.52 to -0.41, all p-values <0.05). The AUC for whole-body PhA was 0.827 (confidence interval [CI] 0.724-0.931, p<0.01) and was 0.883 (CI 0.806-0.961, p<0.01) for EI, and the optimal cutoffs were estimated as 5° (sensitivity 0.84, specificity 0.80) and 0.394 (sensitivity 0.78, specificity 0.95), respectively. When both PhA and EI were included in the model, the AUC increased to 0.905, and this was comparable to that of LFC (AUC = 0.913, p = 0.857).ConclusionsPhA exhibited a correlation with known markers of HF and demonstrated its potential as a non-invasive screening tool for the early detection of HF exacerbation. The combined use of PhA and EI can provide a robust alternative for routine self-monitoring in patients with HF, thereby enhancing early intervention.

Dataset Information

A Personalized Approach to the Management of Congestion in Acute Heart Failure.

Publications

A Personalized Approach to the Management of Congestion in Acute Heart Failure.

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