Concept: Acute decompensated heart failure
Background Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function. Methods We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days. Results Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03). Conclusions In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491 .).
Aggressive diuretic therapy in a patient who is hospitalized for acute decompensated heart failure often leads to progressive renal dysfunction despite persistent congestion. The underlying mechanisms of this so-called acute cardiorenal syndrome are complex and not fully understood.(1),(2) As initial therapy in this setting, ultrafiltration as compared with diuretic therapy may result in a higher rate of sodium and volume removal, with greater weight loss and less frequent rehospitalizations.(3),(4) These findings have suggested that ultrafiltration can provide more effective relief of congestion than pharmacologic therapy can, particularly in the setting of cardiorenal compromise. Ultrafiltration may also reduce diuretic-induced . . .
In acute decompensated heart failure (ADHF) the risk of acute kidney injury (AKI) is high. Early detection of patients at risk for AKI is important. We tested urinary [TIMP-2] × [IGFBP7], a new US Food and Drug Administration-cleared test to assess AKI risk, in a cohort of hospitalized ADHF patients.
Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile.
: Unfortunately, patients with congestive heart failure suffer frequent admissions for the management of fluid overload. Loop diuretics are pivotal in the management of this common clinical problem. Although loop diuretics have been in clinical use since the 1960s, we still do not understand how to optimally administer these drugs. It is unknown why some decompensated heart failure patients exhibit improvements in renal function with diuresis, whereas others display renal function deterioration, limiting attainment of euvolemia. Here the physiologic interactions between the failing heart and kidneys are reviewed. A conceptual framework is presented that emphasizes the balance between tubuloglomerular feedback and venous congestion in determining renal function during loop diuretic use in heart failure. Within this framework, guidelines are derived that seek to maximize the chance for achieving adequate volume removal while maintaining stable or improved renal function during the treatment of acute decompensated heart failure.
Acute decompensated heart failure (ADHF) with associated volume overload is the most common cause of hospitalization in heart failure patients. When accompanied by worsening renal function, it is described as a cardiorenal syndrome and is a therapeutic challenge. Initial treatment commonly encompasses intravenous diuretics however, suboptimal results and high rehospitalization rates have led experts to search for alternative therapeutic strategies. Recent technological advances in extracorporeal therapies have made ultrafiltration a feasible option for treatment of hypervolemia in ADHF. Recent large randomized trials have compared the efficacy and safety of ultrafiltration with diuretics. Additionally, the benefits of novel pharmacologic approaches, including combining hypertonic saline with diuretics, have recently been studied. The aim of this review is to discuss the developments in both pharmacologic and extracorporeal methods for treating hypervolemia in ADHF and acute cardiorenal syndrome.
A rare, yet serious, complication of mechanical heart valves is symptomatic obstructive prosthetic valve thrombosis. The risk of valve thrombosis is magnified in patients who are nonadherent to prescribed anticoagulation. In this case report, we describe a 48-year-old male patient with a history of mechanical aortic valve replacement surgery, who stopped taking prescribed warfarin therapy 2 years before presentation and subsequently developed acute decompensated heart failure secondary to valvular dysfunction. Low-dose alteplase therapy was administered successfully with no bleeding complications and a complete return of valvular function.
Patients with acute decompensated heart failure with diuretic resistance (ADHF-DR) have a poor prognosis. The aim of this study was to assess in patients with ADHF-DR, whether haemodynamic changes during ultrafiltration (UF) are associated with changes in renal function (Δcreatinine) and whether Δcreatinine post UF is associated with mortality.
Acute decompensated heart failure is a serious and common condition where close monitoring of symptoms, vital signs, haemodynamic and other markers are needed after the patient is admitted to hospital as the in-hospital outcome is poor. This review focuses on advances in the assessment and monitoring of these patients.
Soluble CD146 (sCD146), is an endothelial marker with similar diagnostic power as natriuretic peptides in decompensated heart failure (HF). While natriuretic peptides are released by the failing heart, sCD146 may be released by veins in response to stretch induced by systemic congestion in HF. This study investigated the source, effects of vascular stress on release and prognostic properties of sCD146 in HF.