University of Groningen Diuretic response and renal function in heart failure ter Maaten, Jozine Magdalena IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2016 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): ter Maaten, J. M. (2016). Diuretic response and renal function in heart failure. [Groningen]: Rijksuniversiteit Groningen. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 05-04-2019
6 Tackling early heart failure deaths and readmissions by estimating congestion Adriaan A. Voors, and Jozine M. ter Maaten Journal of American College of Cardiology: Heart Failure 2015;3(11):894-895
Tackling early heart failure deaths and readmissions by estimating congestion 113 Patients who are discharged after a hospital admission for heart failure enter a vulnerable phase with a very high risk for early death or heart failure re-admission. 1 This is a major problem for patients, doctors and society. The underlying cause for high readmission rates is still incompletely understood although incomplete decongestion at discharge is frequently suggested to play an important role. Heart failure guidelines recommend a detailed and careful assessment of congestion pre-discharge. 2,3 This includes assessing signs and symptoms and performing a chest X-ray, but sensitivity and specificity of these methods to accurately estimate congestion are limited. 4 Unfortunately, standardized metrics or (de) congestion scores are currently lacking. Several papers were recently published on multiple surrogates used to assess decongestion during hospitalization for acute heart failure. A frequently described surrogate is a rise in hemoglobin during a heart failure admission, indicated as hemoconcentration. Three large studies showed that hemoconcentration was associated with greater weight and fluid loss, greater reductions in filling pressures, and less residual congestion. 5-7 A consistent finding among these three trials was a clear association between greater hemoconcentration and a reduction in early post-discharge events, and heart failure readmission in particular. Diuretic response during hospitalization was recently proposed as another surrogate for decongestion. 8-10 A good diuretic response was associated with greater weight and fluid loss, and less use of inotropes during hospitalization. Moreover, diuretic response was strongly and independently associated with a reduction in early post-discharge events, and lower rates of heart failure rehospitalization. These two examples illustrate that an indirect metric to establish decongestion might be of great value during hospitalization, either to guide therapy or for its prognostic value. However, these metrics were applied during the in-hospital phase, but data on assessment or measures of congestion post-discharge are scarce. In this issue of the journal Duarte et al. examine the prognostic value of plasma volume estimation shortly after discharge for a hospitalization for acute heart failure. 11 The authors performed a retrospective analysis on the EPHESUS (Eplerenone post-acute myocardial infarction heart failure efficacy and survival study) trial. EPHESUS included patients with systolic heart failure following an acute myocardial infarction. Plasma volume variation between discharge and after one month was established by the Strauss formula ( epvs), which incorporates both hemoglobin and hematocrit ratios. An estimation of plasma volume at one month (epvs) was also studied. A decrease in estimated plasma volume ( epvs) one month after discharge was independently associated with a decreased risk of early cardiovascular events, defined as cardiovascular death and/or hospitalization for heart failure. A lower estimated plasma volume at one month (epvs) was similarly associated with less events and provided greater significant prognostic gain compared to epvs. Based on these findings the authors concluded that using a simple estimation of plasma volume, as parameter of congestion status, provides important prognostic information beyond usual 6
114 Chapter 6 clinical variables and may have clinical implications for patient management (i.e. taking serial hemoglobin/hematocrit measurement after discharge). In clinical practice we are all confronted with the heart failure patients indicated as frequent flyers. These patients are hospitalized for acute decompensated heart failure, discharged, and rehospitalized within days to weeks after discharge. It remains difficult to accurately predict which patients are at risk, as the reasons for this are multi-factorial. The social situation, treatment adherence, disease progression, and many other factors play a role. Therefore, predicting heart failure rehospitalization is notoriously more difficult than predicting (cardiovascular) mortality. The present study indicates that relative plasma volume status, calculated from weight and hematocrit, had reasonable correlation with measured plasma volume in healthy volunteers (ρ=0.68; P<0.001), and in chronic heart failure outpatients (ρ=0.51; P<0.001). 12 This study also found that higher relative plasma volume status was associated with the occurrence of death and heart failure hospitalization in stable chronic heart failure patients. To our knowledge, this study is the first to study the use of estimated plasma volume shortly after admission. This proposed metric is a readily applicable and easy accessible tool to assess congestion status, and could be used after discharge. Interestingly, the simple estimation of plasma volume one month post-discharge provided greater prognostic value compared to change in plasma volume from discharge to one month after this, suggesting that not change per se, but plasma volume status postdischarge is sufficient. These patients may have been discharged with residual congestion, and therefore assessment of decongestion during hospitalization either by hemoconcentration, or diuretic response, should be considered, as in patients with limited decongestion, discharge could be postponed. Furthermore, at and after discharge, congestion status could be monitored using estimated plasma volume, by assessing hemoglobin and hematocrit. Adequate, close monitoring of congestion status post-discharge might consequently be actionable and lead to patient tailored therapy. More aggressive up titration of angiotensin converting enzyme(ace) blockers, angiotensin receptor blockers (ARBs), loop diuretics, or the addition of an aldosterone antagonist might be indicated. In fact, a recent study showed that patients with higher rates of recongestion post-discharge were less likely to be on ACE inhibitor, ARBs or aldosterone antagonist. 13 Future studies should validate whether estimated plasma volume can be used to assess (de)congestion both during and after hospitalization in other acute heart failure populations, as this study only included heart failure patients post myocardial infarction. In addition, prospective studies examining the use of estimated plasma volume to guide therapy might enable the clinician to more accurately treat the post-discharge acute heart failure patient and hopefully decrease the frequent flyer phenomenon.
Tackling early heart failure deaths and readmissions by estimating congestion 115 References 1. Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA 2013; 309: 587-93. 2. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787-847. 3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62: e147-239. 4. Gheorghiade M, Follath F, Ponikowski P, et al. Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 2010; 12: 423-33. 5. Testani JM, Chen J, McCauley BD, Kimmel SE, Shannon RP. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation 2010; 122: 265-72. 6. Greene SJ, Gheorghiade M, Vaduganathan M, et al. Haemoconcentration, renal function, and postdischarge outcomes among patients hospitalized for heart failure with reduced ejection fraction: insights from the EVEREST trial. Eur J Heart Fail 2013; 15: 1401-11. 7. van der Meer P, Postmus D, Ponikowski P, et al. The predictive value of short-term changes in hemoglobin concentration in patients presenting with acute decompensated heart failure. J Am Coll Cardiol 2013; 61: 1973-81. 8. Testani JM, Brisco MA, Turner JM, et al. Loop diuretic efficiency: a metric of diuretic responsiveness with prognostic importance in acute decompensated heart failure. Circ Heart Fail 2014; 7: 261-70. 9. Valente MA, Voors AA, Damman K, et al. Diuretic response in acute heart failure: clinical characteristics and prognostic significance. Eur Heart J 2014; 35: 1284-93. 10. ter Maaten JM, Dunning AM, Valente MAE, et al. Diuretic response in acute heart failure - an analysis from ASCEND-HF. American Heart Journal 2015; 170: 313-321. 11. Duarte K, Monnez JM, Albuisson E, Pitt B, Zannad F, Rossignol P. Prognostic value of estimated plasma volume in heart failure. JACC Heart Fail. 2015; 3: 886-893. 12. Ling HZ, Flint J, Damgaard M, et al. Calculated plasma volume status and prognosis in chronic heart failure. Eur J Heart Fail 2015; 17: 35-43. 13. Lala A, McNulty SE, Mentz RJ, et al. Relief and Recurrence of Congestion During and After Hospitalization for Acute Heart Failure: Insights from DOSE-AHF and CARRESS-HF. Circ Heart Fail 2015; 8: 714-718. 6
Part 2 Renal biomarkers heart failure