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Patel S, Green A, Ashokumar S, Hoke A, Rachoin JS. Objective Methods of Assessing Fluid Status to Optimize Volume Management in Kidney Disease and Hypertension: The Importance of Ultrasound. J Clin Med 2023; 12:6368. [PMID: 37835014 PMCID: PMC10573183 DOI: 10.3390/jcm12196368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Fluid overload, a prevalent complication in patients with renal disease and hypertension, significantly impacts patient morbidity and mortality. The daily clinical challenges that clinicians face include how to identify fluid overload early enough in the course of the disease to prevent adverse outcomes and to guide and potentially reduce the intensity of the diuresis. Traditional methods for evaluating fluid status, such as pitting edema, pulmonary crackles, or chest radiography primarily assess extracellular fluid and do not accurately reflect intravascular volume status or venous congestion. This review explores the rationale, mechanism, and evidence behind more recent methods used to assess volume status, namely, lung ultrasound, inferior vena cava (IVC) ultrasound, venous excess ultrasound score, and basic and advanced cardiac echocardiographic techniques. These methods offer a more accurate and objective assessment of fluid status, providing real-time, non-invasive measures of intravascular volume and venous congestion. The methods we discuss are primarily used in inpatient settings, but, given the increased pervasiveness of ultrasound technology, some could soon expand to the outpatient setting.
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Affiliation(s)
- Sharad Patel
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Adam Green
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Sandhya Ashokumar
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
| | - Andrew Hoke
- Department of Medicine, Cooper University Health Care, Camden, NJ 08103, USA;
| | - Jean-Sebastien Rachoin
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
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Phan J, Barroca C, Fernandez J. A Suggested Model for the Vulnerable Phase of Heart Failure: Assessment of Risk Factors, Multidisciplinary Monitoring, Cardiac Rehabilitation, and Addressing the Social Determinants of Health. Cureus 2023; 15:e35602. [PMID: 37007340 PMCID: PMC10063247 DOI: 10.7759/cureus.35602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
The vulnerable phase (VP) of heart failure (HF) is 30 to 90 days after hospital discharge and is associated with increased rehospitalization and mortality rates. The pathophysiological mechanism that drives the VP is due to the progressive increase in left ventricular filling pressure, which can cause hemodynamic congestion and long-term multiorgan injury. Our team analyzed English-written, peer-reviewed research through PubMed from 2018 to 2022, to gather current information on the VP and generate a multipronged approach toward the assessment and intervention of patients with posthospitalization HF. It is our opinion that a structured approach using remote vital monitoring and risk-stratifying tools will be best to identify patients at risk for decompensatory HF during the VP. Medical management can then be targeted toward these high-risk patients by using an organized multidisciplinary team and a disease management program, which includes remote patient-monitoring systems, addressing social determinants of health, and cardiac rehabilitation, to improve rehospitalization and mortality rates.
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Ullah W, Sana MK, Mustafa HU, Sandhyavenu H, Hajduczok A, Mir T, Fischman DL, Shah M, Brailovsky Y, Rajapreyar IN. Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis. Eur J Intern Med 2022; 104:41-48. [PMID: 35644712 DOI: 10.1016/j.ejim.2022.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ultrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited. METHODS Online databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI). RESULTS A total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47-1.07) and all-cause mortality (OR 1.08, 95% CI 0.77-1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38-2.90), all-cause admissions (OR 0.97, 95% CI 0.72-1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21-1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23-1.04) and post-therapy creatinine rise>0.3 mg/dL (OR 1.18, 95% CI 0.74-1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes. CONCLUSIONS In patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.
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Affiliation(s)
- Waqas Ullah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
| | | | - Hamza Usman Mustafa
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - Alexander Hajduczok
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - David L Fischman
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Mahek Shah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Yevgeniy Brailovsky
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Indranee N Rajapreyar
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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McCallum W, Tighiouart H, Testani JM, Griffin M, Konstam MA, Udelson JE, Sarnak MJ. Rates of In-Hospital Decongestion and Association with Mortality and Cardiovascular Outcomes Among Patients Admitted for Acute Heart Failure. Am J Med 2022; 135:e337-e352. [PMID: 35472391 PMCID: PMC10767835 DOI: 10.1016/j.amjmed.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Decongestion is an important goal in the management of acute heart failure. Whether the rate of decongestion is associated with mortality and cardiovascular outcomes is unknown. METHODS Using data from 4133 patients from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression models to evaluate the association between rates of in-hospital change in assessments of volume overload, including b-type natriuretic peptide (BNP), N-terminal pro b-type natriuretic peptide (NT-proBNP), as well as change in hemoconcentration, with risk of all-cause mortality and a composite outcome of cardiovascular mortality or heart failure hospitalization. RESULTS More rapid rates of in-hospital decongestion were associated with decreased risk of mortality and the composite outcome over a median 10-month follow-up. In reference to the quartile of slowest decline, the quartile with the fastest BNP and NT-proBNP decline had lower hazards of mortality (hazard rate [HR] = 0.43 [0.31, 0.59] and HR = 0.27 [0.19, 0.40], respectively) and composite outcome (HR = 0.49 [0.39, 0.60] and HR = 0.54 [0.42, 0.71], respectively). In reference to the quartile of slowest increase, the quartile with the fastest hematocrit increase had lower hazards of mortality (HR = 0.77 [0.62, 0.95]) and composite outcome (HR = 0.75 [0.64, 0.88]). Results were also consistent when models were repeated using propensity-score matching. CONCLUSIONS Faster rates of decongestion are associated with reduced risk of mortality and a composite of cardiovascular mortality and heart failure hospitalization. It remains unknown whether more rapid decongestion provides cardiovascular benefit or whether it serves as a proxy for less treatment resistant heart failure.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Mass.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Mass
| | - Jeffrey M Testani
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Matthew Griffin
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Marvin A Konstam
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Mass
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 593] [Impact Index Per Article: 296.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 674] [Impact Index Per Article: 337.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Kolupoti A, Fudim M, Pandey A, Kucharska-Newton A, Hall ME, Vaduganathan M, Mentz RJ, Caughey MC. Temporal Trends and Prognosis of Physical Examination Findings in Patients With Acute Decompensated Heart Failure: The ARIC Study Community Surveillance. Circ Heart Fail 2021; 14:e008403. [PMID: 34702047 PMCID: PMC8692393 DOI: 10.1161/circheartfailure.121.008403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bedside evaluation of congestion is a mainstay of heart failure (HF) management. Whether detected physical examination signs have changed over time as obesity prevalence has increased in HF populations, or if the associated prognosis differs for HF with reduced or preserved ejection fraction (HFrEF or HFpEF) is uncertain. METHODS From 2005 to 2014, the ARIC study (Atherosclerosis Risk in Communities) conducted adjudicated hospital surveillance of acute decompensated HF. We analyzed trends in physical examination findings, imaging signs, and symptoms related to congestion, both over time and by obesity class, and associated 28-day mortality risks. RESULTS Of 24 937 weighted hospitalizations for acute decompensated HF (mean age 75 years, 53% women, 32% Black), 47% had HFpEF. The prevalence of obesity increased from 2005 to 2014 for both HF types. With increasing obesity category, detected edema increased, while jugular venous distension decreased, and rales remained stable. Detected edema also increased over time, for both HF types. Associations between 28-day mortality and individual signs and symptoms of congestion were similar for HFpEF and HFrEF; however, the adjusted mortality risk with all 3 (edema, rales, and jugular venous distension) versus <3 physical examination findings was higher for patients with HFpEF (odds ratio, 2.41 [95% CI, 1.53-3.79]) than HFrEF (odds ratio, 1.30 [95% CI, 0.87-1.93]); P for interaction by HF type =0.02. CONCLUSIONS In patients hospitalized with acute decompensated HF, detected physical examination findings differ both temporally and by obesity. Combined findings from the physical examination are more prognostic of 28-day mortality for patients with HFpEF than HFrEF.
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Affiliation(s)
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine; Durham, NC
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern; Dallas, TX
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill; Chapel Hill, NC
- Department of Epidemiology, University of Kentucky College of Public Health; Lexington, KY
| | - Michael E. Hall
- Department of Medicine, University of Mississippi Medical Center; Jackson, MS
| | | | - Robert J. Mentz
- Division of Cardiology, Duke University School of Medicine; Durham, NC
| | - Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University; Chapel Hill, NC
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Burden of Heart Failure Signs and Symptoms, Prognosis, and Response to Therapy: The PARAGON-HF Trial. JACC-HEART FAILURE 2021; 9:386-397. [PMID: 33714741 DOI: 10.1016/j.jchf.2021.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study investigated the prognostic importance of heart failure (HF) signs and symptoms in patients with heart failure and preserved ejection fraction (HFpEF), and the effect of sacubitril/valsartan on HF signs and symptoms. BACKGROUND In patients with HFpEF, worsening of HF symptoms, as a marker of cardiac decompensation, is frequently the reason for hospitalization. In this heterogenous disease entity, the prognostic value of HF signs and symptoms with regard to cardiovascular (CV) outcomes is poorly defined. METHODS The authors examined the association between baseline HF signs and symptoms (rest dyspnea, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, fatigue, edema, jugular venous distension, rales, and third heart sound) as well as burden of these HF signs and symptoms (classified as ≤2 and ≥3 HF signs and symptoms) and the primary composite of total HF hospitalizations and CV death, its components, and all-cause death in 4,725 patients enrolled in PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in HFpEF) with available signs and symptoms at randomization. Response to sacubitril/valsartan on the basis of the presence of signs and symptoms was evaluated. Effects of sacubitril/valsartan on signs and symptoms over time were assessed using binary repeated-measures logistic regression. RESULTS Patients with high (≥3) burden of HF signs and symptoms (n = 1,772 [38%]) were more commonly women, had slightly lower left ventricular ejection fractions, higher body mass index, and more advanced New York Heart Association functional class compared with patients with low (≤2) burden (n = 2,953 [62%]) (p < 0.001 for all). Levels of N-terminal pro-B-type natriuretic peptide did not differ significantly between groups (p = 0.14). Greater burden of signs and symptoms was associated with higher risk for total HF hospitalizations and CV death (rate ratio [RR]: 1.50; 95% confidence interval [CI]: 1.30 to 1.74) and all-cause death (RR: 1.41; 95% CI: 1.21 to 1.65). Among individual signs and symptoms, orthopnea (RR: 1.29; 95% CI: 1.04 to 1.61) and rales (RR: 1.52; 95% CI: 1.10 to 2.10) were most predictive of the primary endpoint. Treatment response to sacubitril/valsartan was not significantly modified by burden of HF signs and symptoms (p for interaction = 0.08), though patients with orthopnea appeared to derive greater benefit from sacubitril/valsartan (RR: 0.67; 95% CI: 0.49 to 0.90) than those without orthopnea (RR: 0.97; 95% CI: 0.82 to 1.14; p for interaction = 0.04). Compared with valsartan, sacubitril/valsartan did not significantly decrease overall burden of HF signs and symptoms over time (odds ratio: 0.84; 95% CI: 0.67 to 1.07) but did reduce exertional dyspnea (odds ratio: 0.76; 95% CI: 0.63 to 0.93). CONCLUSIONS High burden of HF signs and symptoms, particularly the presence of orthopnea and rales, portends a higher risk for adverse CV events in patients with HF with preserved ejection fraction. Sacubitril/valsartan did not significantly decrease the burden of HF signs and symptoms over time but did reduce exertional dyspnea relative to valsartan. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Deferrari G, Cipriani A, La Porta E. Renal dysfunction in cardiovascular diseases and its consequences. J Nephrol 2021; 34:137-153. [PMID: 32870495 PMCID: PMC7881972 DOI: 10.1007/s40620-020-00842-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy.
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy.
| | - Adriano Cipriani
- Grown-Up Congentital Heart Disease Center (GUCH Center), Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Rapallo, GE, Italy
| | - Edoardo La Porta
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy
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Lung Ultrasound in Acute Heart Failure: Prevalence of Pulmonary Congestion and Short- and Long-Term Outcomes. JACC-HEART FAILURE 2020; 7:849-858. [PMID: 31582107 DOI: 10.1016/j.jchf.2019.07.008] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES This study sought to assess the prevalence, changes in, and prognostic importance of B-lines, a pulmonary congestion measure by using a simplified lung ultrasonography (LUS) method in acute heart failure (AHF). BACKGROUND Pulmonary congestion is an important finding in AHF, but conventional methods for its detection are insensitive. METHODS In a 2-site, prospective, observational study, 4-zone LUS was performed early during hospitalization for AHF (LUS1) and at discharge (LUS2). B-lines were quantified off-line, blinded to clinical findings and outcomes, by a core laboratory. RESULTS Among 349 patients (median, 75 years of age; 59% men; mean ejection fraction 39%), the sum of B-lines in 4 zones ranged from 0 to 18 (LUS1). The risk of an adverse in-hospital event increased with rising number of B-lines on LUS1: the odds ratio for each B-line tertile was 1.82 (95% confidence interval [CI]: 1.14 to 2.88; p = 0.011). B-line count decreased from a median of 6 (LUS1) to 4 (LUS2; p < 0.001) over 6 days (median). In 132 patients with LUS2 images, the risk of HF hospitalization or all-cause death was greater in patients with a higher number of B-lines at discharge. This relationship was stronger closer to discharge: unadjusted hazard ratio (HR) at 60 days was 3.30 (95% CI: 1.52 to 7.17; p = 0.002); 2.94 at 90 days (95% CI: 1.46 to 5.93; p = 0.003); and 2.01 at 180 days (95% CI: 1.11 to 3.64; p = 0.021). The association between number of B-lines and short- and long-term outcomes persisted after adjusting for important clinical variables, including N-terminal pro-B-type natriuretic peptide. CONCLUSIONS Pulmonary congestion using a simplified 4-zone LUS method was common in patients with AHF and improved with therapy. A higher number of B-lines at baseline and discharge identified patients at increased risk for adverse events.
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11
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A Novel In-hospital Congestion Score to Risk Stratify Patients Admitted for Worsening Heart Failure (from ASCEND-HF). J Cardiovasc Transl Res 2020; 13:540-548. [DOI: 10.1007/s12265-020-09954-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/02/2020] [Indexed: 12/01/2022]
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12
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Massari F, Scicchitano P, Iacoviello M, Valle R, Sanasi M, Piscopo A, Guida P, Mastropasqua F, Caldarola P, Ciccone MM. Serum biochemical determinants of peripheral congestion assessed by bioimpedance vector analysis in acute heart failure. Heart Lung 2019; 48:395-399. [PMID: 31113676 DOI: 10.1016/j.hrtlng.2019.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 01/09/2023]
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13
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Fudim M, Ambrosy AP. A Balancing Act: Preserving Renal Function and the Need for Decongestion. J Card Fail 2019; 25:643-644. [PMID: 31254625 DOI: 10.1016/j.cardfail.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Marat Fudim
- Duke Clinical Research Institute and Division of Cardiology, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
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14
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Sinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med 2019; 30:104-112. [PMID: 31006522 DOI: 10.1016/j.tcm.2019.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 12/21/2022]
Abstract
Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.
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Affiliation(s)
- Lauren Sinnenberg
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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Effect of intravenous carperitide versus nitrates as first-line vasodilators on in-hospital outcomes in hospitalized patients with acute heart failure: Insight from a nationwide claim-based database. Int J Cardiol 2019; 280:104-109. [DOI: 10.1016/j.ijcard.2019.01.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/05/2018] [Accepted: 01/14/2019] [Indexed: 12/28/2022]
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