- Email: [email protected]
Mineralocorticoid Receptor Antagonists can be Used Safely in Heart Failure Patients with Chronic Kidney Disease
The 23rd Annual Scientific Meeting HFSA
S57
146 Mineralocorticoid Receptor Antagonists can be Used Safely in Heart Failure Patients with Chronic Kidney Disease Adam N. Lick, Ken Scholl, Edward M. Geltman; Washington University in St. Louis, St. Louis, MO
145 Residual Congestion on Discharge for Heart Failure Assessed by Impedance Technique Predicts 30-Day and One-Year Heart Failure Death. Results of IMPEDANCE-HF Extended Trial Michael Kleiner Shochat1, Daniel Kapustin2, Marat Fudim3, Ilia Kleiner4, Jean Mark Weinstein4, Ariel Roguin1, Simcha Meisel1; 1Hillel Yaffe Heart Institute, Hadera, Israel; 2University of Toronto Faculty of Medicine, Toronto, ON, Canada; 3Department of Cardiology, Duke University Medical Center, Durham, NC; 4Cardiology Department, University Medical Center, Beer Sheva, Israel Introduction: The aim of secondary analyses of the IMPEDANCE-HF extended trial was to find out if residual congestion on discharge for HF could predict 30-day and one-year Heart Failure death. Methods: The IMPEDANCE-HF extended trial was a randomized controlled single-blinded trial of HF with LVEF 45% and NYHA class II-IV patients (ClinicalTrials.gov NCT01315223). Half of the patients (N=145) were assigned to the active Lung Impedance (LI)-guided treatment arm where clinicians were based therapy on LI level. The other half was assigned to the control arm where LI values were recorded but not conveyed to the clinical treatment team. A non-invasive impedance device (“CardioSet”, Tel Aviv) was used to assess the lung fluid content. Unlike the existing impedance devices, the present device can differentiate a true signal from the lungs from the noise signal of surrounding chest wall and enables to measure a small change in lung fluid content. A method to determine individual “dry” baseline LI (BLI) for each HF patient has been reported. BLI for each patient was used to calculate a new parameter, the ΔLIR= [(current LI/BLI)-1] £ 100%, which determinate the degree of pulmonary congestion in time of measurement. Method. Degree of pulmonary congestion at discharge for HF hospitalization was divided into 5 categories. (1) ΔLIR= 0 to 18% - minimal interstitial edema (IE), (2) ΔLIR= - 18.1 to -28% - mild IE, (3) ΔLIR= -28.1 to - 38 - moderate IE, (4) ΔLIR= -38.1 to -48% - severe IE to mild alveolar edema (AE) and (5) ΔLIR < -48.1% - moderate AE. Results: LI-guided patients were followed for 61.9.4§39.6 months and control patients for 46.7§33.3 months (p<0.01) accounting for 269 and 470 HF hospitalizations, respectively (p<0.01). Twenty-five and 57 HF-associated deaths were recorded during followup (p<0.01) representing a mortality rate of 0.03 and 0.1 per patient £ year follow up in the LI-guided and control group, respectively (p<0.01). Probability of HF death within 30-day and one year is presented on figure. Conclusions: The degree of pre-discharge pulmonary congestion as assessed by LI is a very robust and reliable predictor for 30-day and one-year HF death. Discharge of patients with pulmonary congestion corresponding to categories 4 and 5 is unacceptable and associated with 30-day and one-year mortality more than 80%.
Introduction: The mineralocorticoid receptor antagonists (MRAs) have been shown to be beneficial in heart failure (HF), improving survival and reducing hospitalizations. The AHA/ACC guidelines now give a Class 1A recommendation to use MRAs in NYHA class II-IV HFrEF. There are concerns about the risk for hyperkalemia and renal injury for patients (pts) with HF and chronic kidney disease (CKD). Previous trials have excluded pts with a serum creatinine (Cr) >2.5 mg/dL or an eGFR of <30 mL/min per 1.73 m2. The available data are insufficient to evaluate the benefits and risks of MRAs in pts with HF and CKD. Hypothesis: We hypothesize that MRAs can be used safely in patients with HF and CKD when followed closely. Methods: This is a retrospective study of pts whose data are in our EMR and started a MRA between January 2012 to September 2017. Eligible pts were age 18 years with HF followed in cardiology clinic. Selected pts were receiving MRAs and stratified by CKD based on a Cr 2.5 and/or eGFR <60. Of the 2831 pts who met the initial screening criteria, 40 were randomly selected for this preliminary analysis. Group CKD had 20 patients, 25% men, age 79§13, Cr 1.50§0.52, eGFR 40.4§14.4. Group HF had 20 patients, 35% men, age 62§13, Cr 0.89§0.23, eGFR 98.2§31.4. We tabulated the number of discontinuations (DCs) of MRAs and the reason for DC at each of the first 3 clinic visits following the initialization of MRAs. The primary outcome was the number of pts with a DC of MRA. Secondary outcomes included reasons for DC, hospitalizations, changes in Cr and eGFR and the type of physician ordering the DC. All outcomes were analyzed with Fisher’s exact and paired T-test as appropriate. Results: Average follow up intervals were 2.1, 3.4 and 1.9 months for CKD (total 7.4§6.0 months) vs. 2.3, 2.5 and 3.4 months in HF (total 8.1§5.2 months). At the first follow up, there were no DCs in Group CKD compared with 1 in Group HF. At the final visit, there were 8 DCs in Group CKD vs. 2 in Group HF (p=0.06). Of the 8 total DCs in the CKD arm, 5 were for worsening renal function and 2 for hyperkalemia. There were 18 hospitalizations in the CKD arm through the final visit; only 2 were for worsening renal failure, but 9 were for HF. There were 11 hospitalizations in group HF. Average Cr and eGFR were 0.9§0.2 and 98.2§31.4 at baseline and 1.0§ 0.3 and 89.7§32.5 at the final visit in Group HF (p=NS for both). Conversely, Cr and eGFR in Group CKD were 1.5§0.5 and 40.4§14.4 at baseline and 1.6§0.6 and 37.1§13.0 at the final visit (p=0.08 and p=0.05). Conclusions: There was a trend towards higher DCs of MRAs in the CKD group, mostly due to worsening renal function, with good recovery after DC. However there were only 2 hospitalizations cited for worsening renal failure compared with 9 for worsening HF. There was no significant change in eGFR from baseline to the final visit in the HF group. There was a small, significant decrease in eGFR in the CKD arm. Our data indicate that MRAs can be used safely in patients with both HF and CKD, when monitored closely.
147 Outcomes of Acute Pancreatitis in Patients with Heart Failure: Insights from the Nationwide Inpatient Sample Harsh Mehta1, Ishani Shah2, Mohit Pahuja3, Saad Amin1, Abhishek Bhurwal4, Shruti Moni5, Keith Hawthorne1; 1Saint Barnabas Medical Center, West Orange, NJ; 2 SJHMC, Phoenix, AZ; 3DMC, Detroit, MI; 4Rutgers RWJMS, New Brunswick, NJ; 5 USF, Tampa, FL Introduction: Acute pancreatitis (AP) is an inflammatory process involving the pancreas that presents as severe epigastric pain, associated with nausea and vomiting. Aggressive fluid resuscitation is extremely important to prevent local and systemic complications of AP and has been shown to reduce mortality from AP. However, limited data exists to assess the safety of fluid resuscitation among patients predisposed to volume overload, specifically congestive heart failure (CHF). The aim of our study was to assess mortality outcomes and complications of AP in patients with a concurrent CHF. Methods: Using the Nationwide Inpatient Sample (NIS), retrospective analysis of hospitalized patients 18 years, with a primary diagnosis of acute pancreatitis during a five-year period (2010-2014) was performed. Patients were divided into two groups - with and without CHF. Primary outcomes were inpatient mortality and length of stay. Secondary outcomes were respiratory failure, mechanical ventilation, and need for vasopressors. Descriptive analyses were compared using the t-test for continuous data and chi-square test for categorical data. Statistical significance was assigned at P<0.05. Results: A total of 1,356,659 patients were hospitalized with a primary diagnosis of AP, out of which 69,657 patients had CHF. Patients in the CHF group were older (68.29 vs 51.13 years, p<0.001), and Medicare was predominant primary payer (69.69 vs 29.36%, p<0.001). Other demographic variables like gender, race, geographical location, hospital bed-size, etc were similar. Coronary artery disease, hypertension, DM, dyslipidemia, obesity, chronic kidney disease and lung disease were more common in the CHF group, while chronic liver disease, smoking and alcohol use were more common in the group without CHF. Patients in the CHF group were more likely to develop respiratory failure (9.57 vs 2.34%, p<0.001) and get intubated (4.90 vs 1.56, p<0.001). Intubation was independently associated with significantly higher mortality [OR-23.39 (14.29,38.29), p<0.001]. Overall inpatient mortality (3.16 vs 0.67%, p<0.001) and length of stay (6.75 vs 4.67 days) was higher in the CHF group. On multivariate regression, HF was indepen-
S57
146 Mineralocorticoid Receptor Antagonists can be Used Safely in Heart Failure Patients with Chronic Kidney Disease Adam N. Lick, Ken Scholl, Edward M. Geltman; Washington University in St. Louis, St. Louis, MO
145 Residual Congestion on Discharge for Heart Failure Assessed by Impedance Technique Predicts 30-Day and One-Year Heart Failure Death. Results of IMPEDANCE-HF Extended Trial Michael Kleiner Shochat1, Daniel Kapustin2, Marat Fudim3, Ilia Kleiner4, Jean Mark Weinstein4, Ariel Roguin1, Simcha Meisel1; 1Hillel Yaffe Heart Institute, Hadera, Israel; 2University of Toronto Faculty of Medicine, Toronto, ON, Canada; 3Department of Cardiology, Duke University Medical Center, Durham, NC; 4Cardiology Department, University Medical Center, Beer Sheva, Israel Introduction: The aim of secondary analyses of the IMPEDANCE-HF extended trial was to find out if residual congestion on discharge for HF could predict 30-day and one-year Heart Failure death. Methods: The IMPEDANCE-HF extended trial was a randomized controlled single-blinded trial of HF with LVEF 45% and NYHA class II-IV patients (ClinicalTrials.gov NCT01315223). Half of the patients (N=145) were assigned to the active Lung Impedance (LI)-guided treatment arm where clinicians were based therapy on LI level. The other half was assigned to the control arm where LI values were recorded but not conveyed to the clinical treatment team. A non-invasive impedance device (“CardioSet”, Tel Aviv) was used to assess the lung fluid content. Unlike the existing impedance devices, the present device can differentiate a true signal from the lungs from the noise signal of surrounding chest wall and enables to measure a small change in lung fluid content. A method to determine individual “dry” baseline LI (BLI) for each HF patient has been reported. BLI for each patient was used to calculate a new parameter, the ΔLIR= [(current LI/BLI)-1] £ 100%, which determinate the degree of pulmonary congestion in time of measurement. Method. Degree of pulmonary congestion at discharge for HF hospitalization was divided into 5 categories. (1) ΔLIR= 0 to 18% - minimal interstitial edema (IE), (2) ΔLIR= - 18.1 to -28% - mild IE, (3) ΔLIR= -28.1 to - 38 - moderate IE, (4) ΔLIR= -38.1 to -48% - severe IE to mild alveolar edema (AE) and (5) ΔLIR < -48.1% - moderate AE. Results: LI-guided patients were followed for 61.9.4§39.6 months and control patients for 46.7§33.3 months (p<0.01) accounting for 269 and 470 HF hospitalizations, respectively (p<0.01). Twenty-five and 57 HF-associated deaths were recorded during followup (p<0.01) representing a mortality rate of 0.03 and 0.1 per patient £ year follow up in the LI-guided and control group, respectively (p<0.01). Probability of HF death within 30-day and one year is presented on figure. Conclusions: The degree of pre-discharge pulmonary congestion as assessed by LI is a very robust and reliable predictor for 30-day and one-year HF death. Discharge of patients with pulmonary congestion corresponding to categories 4 and 5 is unacceptable and associated with 30-day and one-year mortality more than 80%.
Introduction: The mineralocorticoid receptor antagonists (MRAs) have been shown to be beneficial in heart failure (HF), improving survival and reducing hospitalizations. The AHA/ACC guidelines now give a Class 1A recommendation to use MRAs in NYHA class II-IV HFrEF. There are concerns about the risk for hyperkalemia and renal injury for patients (pts) with HF and chronic kidney disease (CKD). Previous trials have excluded pts with a serum creatinine (Cr) >2.5 mg/dL or an eGFR of <30 mL/min per 1.73 m2. The available data are insufficient to evaluate the benefits and risks of MRAs in pts with HF and CKD. Hypothesis: We hypothesize that MRAs can be used safely in patients with HF and CKD when followed closely. Methods: This is a retrospective study of pts whose data are in our EMR and started a MRA between January 2012 to September 2017. Eligible pts were age 18 years with HF followed in cardiology clinic. Selected pts were receiving MRAs and stratified by CKD based on a Cr 2.5 and/or eGFR <60. Of the 2831 pts who met the initial screening criteria, 40 were randomly selected for this preliminary analysis. Group CKD had 20 patients, 25% men, age 79§13, Cr 1.50§0.52, eGFR 40.4§14.4. Group HF had 20 patients, 35% men, age 62§13, Cr 0.89§0.23, eGFR 98.2§31.4. We tabulated the number of discontinuations (DCs) of MRAs and the reason for DC at each of the first 3 clinic visits following the initialization of MRAs. The primary outcome was the number of pts with a DC of MRA. Secondary outcomes included reasons for DC, hospitalizations, changes in Cr and eGFR and the type of physician ordering the DC. All outcomes were analyzed with Fisher’s exact and paired T-test as appropriate. Results: Average follow up intervals were 2.1, 3.4 and 1.9 months for CKD (total 7.4§6.0 months) vs. 2.3, 2.5 and 3.4 months in HF (total 8.1§5.2 months). At the first follow up, there were no DCs in Group CKD compared with 1 in Group HF. At the final visit, there were 8 DCs in Group CKD vs. 2 in Group HF (p=0.06). Of the 8 total DCs in the CKD arm, 5 were for worsening renal function and 2 for hyperkalemia. There were 18 hospitalizations in the CKD arm through the final visit; only 2 were for worsening renal failure, but 9 were for HF. There were 11 hospitalizations in group HF. Average Cr and eGFR were 0.9§0.2 and 98.2§31.4 at baseline and 1.0§ 0.3 and 89.7§32.5 at the final visit in Group HF (p=NS for both). Conversely, Cr and eGFR in Group CKD were 1.5§0.5 and 40.4§14.4 at baseline and 1.6§0.6 and 37.1§13.0 at the final visit (p=0.08 and p=0.05). Conclusions: There was a trend towards higher DCs of MRAs in the CKD group, mostly due to worsening renal function, with good recovery after DC. However there were only 2 hospitalizations cited for worsening renal failure compared with 9 for worsening HF. There was no significant change in eGFR from baseline to the final visit in the HF group. There was a small, significant decrease in eGFR in the CKD arm. Our data indicate that MRAs can be used safely in patients with both HF and CKD, when monitored closely.
147 Outcomes of Acute Pancreatitis in Patients with Heart Failure: Insights from the Nationwide Inpatient Sample Harsh Mehta1, Ishani Shah2, Mohit Pahuja3, Saad Amin1, Abhishek Bhurwal4, Shruti Moni5, Keith Hawthorne1; 1Saint Barnabas Medical Center, West Orange, NJ; 2 SJHMC, Phoenix, AZ; 3DMC, Detroit, MI; 4Rutgers RWJMS, New Brunswick, NJ; 5 USF, Tampa, FL Introduction: Acute pancreatitis (AP) is an inflammatory process involving the pancreas that presents as severe epigastric pain, associated with nausea and vomiting. Aggressive fluid resuscitation is extremely important to prevent local and systemic complications of AP and has been shown to reduce mortality from AP. However, limited data exists to assess the safety of fluid resuscitation among patients predisposed to volume overload, specifically congestive heart failure (CHF). The aim of our study was to assess mortality outcomes and complications of AP in patients with a concurrent CHF. Methods: Using the Nationwide Inpatient Sample (NIS), retrospective analysis of hospitalized patients 18 years, with a primary diagnosis of acute pancreatitis during a five-year period (2010-2014) was performed. Patients were divided into two groups - with and without CHF. Primary outcomes were inpatient mortality and length of stay. Secondary outcomes were respiratory failure, mechanical ventilation, and need for vasopressors. Descriptive analyses were compared using the t-test for continuous data and chi-square test for categorical data. Statistical significance was assigned at P<0.05. Results: A total of 1,356,659 patients were hospitalized with a primary diagnosis of AP, out of which 69,657 patients had CHF. Patients in the CHF group were older (68.29 vs 51.13 years, p<0.001), and Medicare was predominant primary payer (69.69 vs 29.36%, p<0.001). Other demographic variables like gender, race, geographical location, hospital bed-size, etc were similar. Coronary artery disease, hypertension, DM, dyslipidemia, obesity, chronic kidney disease and lung disease were more common in the CHF group, while chronic liver disease, smoking and alcohol use were more common in the group without CHF. Patients in the CHF group were more likely to develop respiratory failure (9.57 vs 2.34%, p<0.001) and get intubated (4.90 vs 1.56, p<0.001). Intubation was independently associated with significantly higher mortality [OR-23.39 (14.29,38.29), p<0.001]. Overall inpatient mortality (3.16 vs 0.67%, p<0.001) and length of stay (6.75 vs 4.67 days) was higher in the CHF group. On multivariate regression, HF was indepen-