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Ultrafiltration is Associated with Worsening Renal Function, and Electrolyte Abnormalities in Patients with Diuretic Refractory Heart Failure and Renal Dysfunction
S96 Journal of Cardiac Failure Vol. 17 No. 8S August 2011
of diuretic efficacy in ADHF moderately correlates with weight changes. Education about the limitations of net fluid status could improve diuretic titration.
repeat UF sessions or were enrolled in a clinical trial of UF therapy. Paired comparisons were evaluated using the Wilcoxon matched-pairs signed-rank test for nonparametric values. Results: 72 patients were eligible for the study (median age 61 [IQR (51-70)], 54% men, 61% Caucasian, 54% with EF $40%). On admission, median BUN was 50 [IQR (33-78)], creatinine 1.9 [IQR (1.4-2.8)], SBP was 110 [IQR (98-125)] and GFR was 38. Ultrafiltration was initiated on median hospital day 7 [IQR (4-13)], and 44% of patients received vasoactive therapy prior to ultrafiltration. Median total fluid removal was 11.3 L (IQR [7.7-14.7]) and median weight loss (pre vs. post-ultrafiltration) was 10 kg (IQR [-13, -7] p ! 0.0001), and the most common complication of UF was a clotted catheter (n527, 38%). Comparing pre and postultrafiltration, median BUN increased from 59 (IQR [41, 79]) to 72 (IQR [50, 90]) and median serum creatinine increased from 2.1(IQR [1.6, 2.8]) to 2.3 (IQR [1.8, 3.4]), respectively. There were significant changes in serum electrolytes with a decrease in median serum sodium from 135 (IQR [132, 139]) to 134 (IQR [129, 136]), p!0.0001) and an increase in median serum potassium (4.1(IQR [3.8, 4.6]) to 4.7(IQR [4.3, 5.1]), p!0.0001). Seven patients (10%) required initiation of dialysis, four patients (6%) died during hospitalization, three (4%) patients were discharged to hospice care, and two (3%) patients underwent left ventricular device placement or cardiac transplantation (within 6 months). Median length of stay was 17 days (IQR [10.5, 26.5]). Conclusion: In hospitalized patients with heart failure who were refractory to diuretics, ultrafiltration achieved significant weight loss and fluid removal but at the cost of worsening short-term renal function, and electrolyte abnormalities. Further research to identify the appropriate population for ultrafiltration, long term outcomes, and the intensity of treatment is required to refine this therapy.
307 Symptom-Monitoring and Treatment-Seeking Behaviors in Japanese Patients with Heart Failure: A Multicenter Study Naoko Kato1, Koichiro Kinugawa1, Etsuko Nakayama2, Akiko Hatakeyama2, Yumiko Kumagai2, Taro Shiga1, Masaru Hatano1, Atsushi Yao1, Chikako Miura2, Masayoshi Nagayama3, Tetsuya Sumiyoshi3, Ryozo Nagai1; 1Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; 2Nursing, Sakakibara Heart Institute, Tokyo, Japan; 3Cardiology, Sakakibara Heart Institute, Tokyo, Japan Background: Outpatients with heart failure (HF) often wait for days before seeking care even after manifestation of symptoms. This delay sometimes leads into critical outcome and should be avoided. Routine monitoring is important for the recognition of initial symptoms albeit mild, and helps patients to seek appropriate care earlier. Behaviors for symptom-monitoring and treatment-seeking can be evaluated with a part of European Heart Failure Self-Care Behavior Scale. We previously established the modified version of this scale for Japanese. Aim: To clarify which factors can be related with poor behaviors for symptom-monitoring and treatment-seeking among Japanese patients with HF. Methods: We applied a cross-sectional survey of HF patients in two independent hospitals. Scores from five items in the above-mentioned Japanese scale regarding daily weighing and contacting healthcare providers were used to quantify symptom-monitoring and treatment-seeking behaviors. To identify related factors, univariate analysis and multivariate analysis were performed. Results: A total of 135 patients were included (70.0% males; mean age 62.8 6 13.7 years). Mean left ventricular ejection fraction (LVEF) was 42.3 6 17.2%, and 38.3% of patients had preserved LVEF ($50%). Fifty-nine percent of patients performed daily weight monitoring, but only 34% contacted healthcare providers if their weight gained 2 kg (w4.5 lbs) within one week. Multiple regression analysis revealed that younger age (standard partial regression coefficients [sb]5-0.22 p50.01), no prior hospitalization for HF (sb5-0.21 p50.02), and preserved LVEF (sb50.22, p50.01) were independent predictors for the poor behaviors. Inadequate knowledge on HF was also associated with the poor behaviors in the univariate analysis (p50.028). Gender, etiology of HF, diabetes mellitus or chronic kidney disease were not related to the behaviors. Conclusions: Education by the health-care providers during hospitalization appears to work well to improve behaviors for symptom-monitoring and treatment-seeking in Japanese patients with HF. This study also suggests that HF patients with younger age or with preserved EF should be more focused.
309 Mortality in Primary Pulmonary Arterial Hypertension Stratified by Hemoglobin Levels Baruch Popovtzer, Jason N. Salamon, Jeremy Mazurek, Muhammad Sardar, Ronald Zolty; Cardiology, Montefiore Medical Center, Bronx, NY Purpose: Anemia has been shown to be an independent predictor of increased morbidity and mortality in multiple chronic conditions including heart failure and coronary artery disease. Primary Pulmonary Arterial Hypertension (PAH) is associated with an increased mortality despite aggressive therapy. We explored if lower hemoglobin (Hb) levels have prognostic significance and are associated with increased mortality and morbidity in patients with PAH. Methods and Materials: In a retrospective cohort fashion, we identified all patients who, over a 13 year period, were diagnosed with PAH, had a pulmonary arterial systolic pressure (PASP) O35 mmHg via echocardiography and had Hb levels drawn. Patients meeting these criteria were divided into 2 groups: those with a low Hg levels (!9 gr/dL) and those with elevated Hb levels (O9 gr/ dL). All-cause mortality and readmission for all-cause and PAH through 5 years after the diagnosis of PAH were obtained. Results: Patients with a lower Hg (Cohort I, N5217) had a higher mortality rate at 5 years compared with those with higher Hg (Cohort II, N5174; 33% vs. 23%, RR5 0.7 CI5 [0.6-0.9], p!0.01). No significant differences in readmission for all cause (Cohort I 95% vs. Cohort II 94%, p50.17) or PAH (Cohort I 64% vs. Cohort II 63% p50.44) were observed at 5 years.
308 Ultrafiltration is Associated with Worsening Renal Function, and Electrolyte Abnormalities in Patients with Diuretic Refractory Heart Failure and Renal Dysfunction Shailesh C. Shirolkar, G. Michael Felker, Susanna R. Stevens, Minnie P. Blackwell, Shelley L. Thompson, Joseph G. Rogers, Christopher M. O’Connor, Sandesh Dev; Duke Clinical Research Institute, Durham, NC Background: The UNLOAD trial reported that ultrafiltration (UF) therapy resulted in greater fluid loss and lower resource utilization compared to diuretic therapy in acute heart failure (HF) without worsening of renal function. Methods: We undertook a retrospective chart review of patients with acute HF who underwent UF at our center for refractory HF from 2006 to 2010. We excluded patients who underwent
Conclusions: Patients with PAH and low Hg levels had increased mortality compared to those with higher Hg levels. However, a significant readmission difference was not seen. Thus, low Hg levels in patients with PAH appears to be a useful marker in assessing those patients with an increased risk of death. Prospective trials are warranted to further investigate these dramatic findings and to determine if increasing Hb levels of PAH patients with anemia will decrease mortality.
of diuretic efficacy in ADHF moderately correlates with weight changes. Education about the limitations of net fluid status could improve diuretic titration.
repeat UF sessions or were enrolled in a clinical trial of UF therapy. Paired comparisons were evaluated using the Wilcoxon matched-pairs signed-rank test for nonparametric values. Results: 72 patients were eligible for the study (median age 61 [IQR (51-70)], 54% men, 61% Caucasian, 54% with EF $40%). On admission, median BUN was 50 [IQR (33-78)], creatinine 1.9 [IQR (1.4-2.8)], SBP was 110 [IQR (98-125)] and GFR was 38. Ultrafiltration was initiated on median hospital day 7 [IQR (4-13)], and 44% of patients received vasoactive therapy prior to ultrafiltration. Median total fluid removal was 11.3 L (IQR [7.7-14.7]) and median weight loss (pre vs. post-ultrafiltration) was 10 kg (IQR [-13, -7] p ! 0.0001), and the most common complication of UF was a clotted catheter (n527, 38%). Comparing pre and postultrafiltration, median BUN increased from 59 (IQR [41, 79]) to 72 (IQR [50, 90]) and median serum creatinine increased from 2.1(IQR [1.6, 2.8]) to 2.3 (IQR [1.8, 3.4]), respectively. There were significant changes in serum electrolytes with a decrease in median serum sodium from 135 (IQR [132, 139]) to 134 (IQR [129, 136]), p!0.0001) and an increase in median serum potassium (4.1(IQR [3.8, 4.6]) to 4.7(IQR [4.3, 5.1]), p!0.0001). Seven patients (10%) required initiation of dialysis, four patients (6%) died during hospitalization, three (4%) patients were discharged to hospice care, and two (3%) patients underwent left ventricular device placement or cardiac transplantation (within 6 months). Median length of stay was 17 days (IQR [10.5, 26.5]). Conclusion: In hospitalized patients with heart failure who were refractory to diuretics, ultrafiltration achieved significant weight loss and fluid removal but at the cost of worsening short-term renal function, and electrolyte abnormalities. Further research to identify the appropriate population for ultrafiltration, long term outcomes, and the intensity of treatment is required to refine this therapy.
307 Symptom-Monitoring and Treatment-Seeking Behaviors in Japanese Patients with Heart Failure: A Multicenter Study Naoko Kato1, Koichiro Kinugawa1, Etsuko Nakayama2, Akiko Hatakeyama2, Yumiko Kumagai2, Taro Shiga1, Masaru Hatano1, Atsushi Yao1, Chikako Miura2, Masayoshi Nagayama3, Tetsuya Sumiyoshi3, Ryozo Nagai1; 1Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; 2Nursing, Sakakibara Heart Institute, Tokyo, Japan; 3Cardiology, Sakakibara Heart Institute, Tokyo, Japan Background: Outpatients with heart failure (HF) often wait for days before seeking care even after manifestation of symptoms. This delay sometimes leads into critical outcome and should be avoided. Routine monitoring is important for the recognition of initial symptoms albeit mild, and helps patients to seek appropriate care earlier. Behaviors for symptom-monitoring and treatment-seeking can be evaluated with a part of European Heart Failure Self-Care Behavior Scale. We previously established the modified version of this scale for Japanese. Aim: To clarify which factors can be related with poor behaviors for symptom-monitoring and treatment-seeking among Japanese patients with HF. Methods: We applied a cross-sectional survey of HF patients in two independent hospitals. Scores from five items in the above-mentioned Japanese scale regarding daily weighing and contacting healthcare providers were used to quantify symptom-monitoring and treatment-seeking behaviors. To identify related factors, univariate analysis and multivariate analysis were performed. Results: A total of 135 patients were included (70.0% males; mean age 62.8 6 13.7 years). Mean left ventricular ejection fraction (LVEF) was 42.3 6 17.2%, and 38.3% of patients had preserved LVEF ($50%). Fifty-nine percent of patients performed daily weight monitoring, but only 34% contacted healthcare providers if their weight gained 2 kg (w4.5 lbs) within one week. Multiple regression analysis revealed that younger age (standard partial regression coefficients [sb]5-0.22 p50.01), no prior hospitalization for HF (sb5-0.21 p50.02), and preserved LVEF (sb50.22, p50.01) were independent predictors for the poor behaviors. Inadequate knowledge on HF was also associated with the poor behaviors in the univariate analysis (p50.028). Gender, etiology of HF, diabetes mellitus or chronic kidney disease were not related to the behaviors. Conclusions: Education by the health-care providers during hospitalization appears to work well to improve behaviors for symptom-monitoring and treatment-seeking in Japanese patients with HF. This study also suggests that HF patients with younger age or with preserved EF should be more focused.
309 Mortality in Primary Pulmonary Arterial Hypertension Stratified by Hemoglobin Levels Baruch Popovtzer, Jason N. Salamon, Jeremy Mazurek, Muhammad Sardar, Ronald Zolty; Cardiology, Montefiore Medical Center, Bronx, NY Purpose: Anemia has been shown to be an independent predictor of increased morbidity and mortality in multiple chronic conditions including heart failure and coronary artery disease. Primary Pulmonary Arterial Hypertension (PAH) is associated with an increased mortality despite aggressive therapy. We explored if lower hemoglobin (Hb) levels have prognostic significance and are associated with increased mortality and morbidity in patients with PAH. Methods and Materials: In a retrospective cohort fashion, we identified all patients who, over a 13 year period, were diagnosed with PAH, had a pulmonary arterial systolic pressure (PASP) O35 mmHg via echocardiography and had Hb levels drawn. Patients meeting these criteria were divided into 2 groups: those with a low Hg levels (!9 gr/dL) and those with elevated Hb levels (O9 gr/ dL). All-cause mortality and readmission for all-cause and PAH through 5 years after the diagnosis of PAH were obtained. Results: Patients with a lower Hg (Cohort I, N5217) had a higher mortality rate at 5 years compared with those with higher Hg (Cohort II, N5174; 33% vs. 23%, RR5 0.7 CI5 [0.6-0.9], p!0.01). No significant differences in readmission for all cause (Cohort I 95% vs. Cohort II 94%, p50.17) or PAH (Cohort I 64% vs. Cohort II 63% p50.44) were observed at 5 years.
308 Ultrafiltration is Associated with Worsening Renal Function, and Electrolyte Abnormalities in Patients with Diuretic Refractory Heart Failure and Renal Dysfunction Shailesh C. Shirolkar, G. Michael Felker, Susanna R. Stevens, Minnie P. Blackwell, Shelley L. Thompson, Joseph G. Rogers, Christopher M. O’Connor, Sandesh Dev; Duke Clinical Research Institute, Durham, NC Background: The UNLOAD trial reported that ultrafiltration (UF) therapy resulted in greater fluid loss and lower resource utilization compared to diuretic therapy in acute heart failure (HF) without worsening of renal function. Methods: We undertook a retrospective chart review of patients with acute HF who underwent UF at our center for refractory HF from 2006 to 2010. We excluded patients who underwent
Conclusions: Patients with PAH and low Hg levels had increased mortality compared to those with higher Hg levels. However, a significant readmission difference was not seen. Thus, low Hg levels in patients with PAH appears to be a useful marker in assessing those patients with an increased risk of death. Prospective trials are warranted to further investigate these dramatic findings and to determine if increasing Hb levels of PAH patients with anemia will decrease mortality.