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A Systematic Review of Cardiogenic Shock in the Setting of Severe Aortic Stenosis: Prevalence, Management and Outcomes
The 23rd Annual Scientific Meeting HFSA
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Background: Worsening renal function (WRF) occurs commonly during episodes of acute heart failure (AHF). However, the association between left ventricular ejection fraction (LVEF) and WRF in patients with AHF is uncertain. Consequently, we assessed the development of WRF over a broad range of LVEF in patients with a broad range of LVEF who were hospitalized with AHF. Methods: We analyzed data from 6,128 patients enrolled in the in RELAX-AHF 2 trial who had LVEF measured during AHF hospitalization. Patients were categorized in quartiles according to LVEF: Q1, LVEF 7-29%; Q2, LVEF 29-38%; Q3, LVEF 38-50% and Q4, LVEF 5087%. WRF was defined as a rise in serum creatinine of 0.3 mg/dL from baseline through day 5 in the hospital. Results: The incidence of WRF through hospital day 5 was higher in the HFpEF cohort (Q4) compared with the lowest LVEF group (Q1) (34.3% vs. 23%; OR 1.94, 95%CI 1.52-2.48, P<0.001) and this difference persisted after multivariate analysis (adjusted OR 1.36, 95%CI 1.01-1.83, p=0.042) (Figure 1 and Table 1). Notably, weight loss was significantly less in Q4 than in Q1 patients (weight kg Median: 3.18 vs. 3.95, P<0.001). HFpEF patients (Q4) also demonstrated more evidence of residual congestion (clinical congestion [any sign/symptom of edema (35.1% vs. 32.3%), high JVP (9.0% vs. 6.8%), orthopnea (16.8% vs. 15.2%)] at day 5 compared to HFrEF patients(Q1). Conclusions: WRF during AHF hospitalization was higher in HFpEF than in HFrEF patients. Evidence of a lower weight loss and persistence of residual congestion in HFpEF vs HFrEF patients were factors associated with WRF in HFpEF group. These findings demonstrate that HFpEF patients are more likely to develop WRF during AHF hospitalization than HFrEF patients and they suggest that residual congestion may play a role in this process. Multivariable analysis for WRF across LVEF categories
LVEF Q1 (7-29%) LVEF Q2 (29-38%) LVEF Q3 (38-50%) LVEF Q4 (50-87%)
Model 1- no adjust, OR (95%CI)/ P value
Model 2- adjusted for age and gender, OR (95%CI) / P value
Model 3- adjusted for age, gender and others, OR (95%CI) / P value
ref 1.32 (1.05-1.66) 0.017 1.52 (1.22-1.90) <0.001 1.94 (1.52-2.48) <0.001
ref 1.26 (1-1.58) 0.049 1.37 (1.09-1.72) 0.007 1.67 (1.3-2.17) <0.001
ref 1.19 (0.94-1.52) 0.151 1.17 (0.90-1.51) 0.237 1.36 (1.01-1.83) 0.042
129 A Systematic Review of Cardiogenic Shock in the Setting of Severe Aortic Stenosis: Prevalence, Management and Outcomes Mohammed Essa, Ehimen Aneni, Cecilia Bernardi, James Fleming, Maria Paredes, Katherine Frumento, Medhat Abdelmessih, Lissa Sugeng, Lavanya Bellumkonda; Yale School of Medicine, New Haven, CT Background: Cardiogenic shock (CS) management has evolved over the recent years especially after the development of mechanical circulatory support devices (MCS). Aortic stenosis (AS) is the most common valvular heart disease, yet little is known about the prevalence, management, and mortality of the AS and CS combination. Methods: A systematic search was conducted to identify studies that included patients with combined AS and CS using EMBASE, MEDLINE, and Scopus. Primary outcomes included in-hospital, 30-day, and 1-year mortality. Additional outcomes included procedure-related complications. The study protocol was registered at PROSPERO (CRD42018112245). Results: A total of 10 studies representing 338 patients were included. Prevalence of AS presenting with CS ranged from 3.5% to 12%. In-hospital mortality ranged from 43% to 77% in patients treated with Balloon Aortic Valvuloplasty (BAV), 0% and 11% in patients who underwent surgical valve replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR) respectively. In patients undergoing BAV, 30-day mortality varied between 50% and 55%, and between 19% and 33% in those treated with TAVR. Delaying valve intervention for more than 48 hours was found to negatively impact survival after BAV. There was limited evidence on the use of Mechanical Circulatory Support (MCS). Conclusion: AS presenting with CS is a fatal condition with no clarity of management strategy. Time to intervention on the valve is critical. Valve replacement through either SAVR or TAVR had better outcomes compared to BAV alone. There is limited evidence on MCS as a management strategy in patients with AS complicated by CS.
130 Association between Left Ventricular Ejection Fraction and Worsening Renal Function in Acute Heart Failure: Insights from the RELAX-AHF-2 Trial Siting Feng, Satit Janwanishstaporn, John R. Teerlink, Marco Cotter G. Metra, Beth A. Davison, G. Michael Felker, Gerasimos Filippatos, Peter S. Pang, Piotr Ponikowski, Thomas Severin, Claudio Gimpelewicz, I.E. Sama, Adriaan A. Voors, Barry H. Greenberg; University of California San Diego, San Diego, CA
131 Relationship between “Dry Weight” and Actual Weight Loss in Patients Hospitalized for Heart Failure J. Fleming, M. Griffin, J. Ivey-Miranda, P. Raghavendra, G. Struyk, P. Shamlian, N. Gomez, J. Barnett, B. Stewart, E. Wycallis, A. Thomas, D. Mahoney, M. Pattoli, V. Rao, J. Testani; Yale University School of Medicine, New Haven, CT Introduction: In the treatment of patients with acute decompensated heart failure (ADHF) estimation of the degree of volume overload is critical in guiding the goals of diuretic therapy. A “dry weight,” or the weight of a patient when they are euvolemic, is commonly used by clinicians to determine when to discontinue diuretic therapy during hospitalization. However, it is unclear how this dry weight relates to the actual weight loss achieved during hospitalization. Hypothesis: Dry weight will have limited correlation with the ultimate weight loss achieved during hospitalization. Methods: Patients hospitalized for ADHF with volume overload and receiving IV diuretics were enrolled. Each participant completed a clinical assessment survey that asked, “How many pounds of water weight are you above your dry weight?” We additionally extracted any dry weight that was documented in the electronic medical record (EMR) and the lowest documented weight in the EMR within the previous year. The primary comparison was to evaluate the correlation between the patients’
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Background: Worsening renal function (WRF) occurs commonly during episodes of acute heart failure (AHF). However, the association between left ventricular ejection fraction (LVEF) and WRF in patients with AHF is uncertain. Consequently, we assessed the development of WRF over a broad range of LVEF in patients with a broad range of LVEF who were hospitalized with AHF. Methods: We analyzed data from 6,128 patients enrolled in the in RELAX-AHF 2 trial who had LVEF measured during AHF hospitalization. Patients were categorized in quartiles according to LVEF: Q1, LVEF 7-29%; Q2, LVEF 29-38%; Q3, LVEF 38-50% and Q4, LVEF 5087%. WRF was defined as a rise in serum creatinine of 0.3 mg/dL from baseline through day 5 in the hospital. Results: The incidence of WRF through hospital day 5 was higher in the HFpEF cohort (Q4) compared with the lowest LVEF group (Q1) (34.3% vs. 23%; OR 1.94, 95%CI 1.52-2.48, P<0.001) and this difference persisted after multivariate analysis (adjusted OR 1.36, 95%CI 1.01-1.83, p=0.042) (Figure 1 and Table 1). Notably, weight loss was significantly less in Q4 than in Q1 patients (weight kg Median: 3.18 vs. 3.95, P<0.001). HFpEF patients (Q4) also demonstrated more evidence of residual congestion (clinical congestion [any sign/symptom of edema (35.1% vs. 32.3%), high JVP (9.0% vs. 6.8%), orthopnea (16.8% vs. 15.2%)] at day 5 compared to HFrEF patients(Q1). Conclusions: WRF during AHF hospitalization was higher in HFpEF than in HFrEF patients. Evidence of a lower weight loss and persistence of residual congestion in HFpEF vs HFrEF patients were factors associated with WRF in HFpEF group. These findings demonstrate that HFpEF patients are more likely to develop WRF during AHF hospitalization than HFrEF patients and they suggest that residual congestion may play a role in this process. Multivariable analysis for WRF across LVEF categories
LVEF Q1 (7-29%) LVEF Q2 (29-38%) LVEF Q3 (38-50%) LVEF Q4 (50-87%)
Model 1- no adjust, OR (95%CI)/ P value
Model 2- adjusted for age and gender, OR (95%CI) / P value
Model 3- adjusted for age, gender and others, OR (95%CI) / P value
ref 1.32 (1.05-1.66) 0.017 1.52 (1.22-1.90) <0.001 1.94 (1.52-2.48) <0.001
ref 1.26 (1-1.58) 0.049 1.37 (1.09-1.72) 0.007 1.67 (1.3-2.17) <0.001
ref 1.19 (0.94-1.52) 0.151 1.17 (0.90-1.51) 0.237 1.36 (1.01-1.83) 0.042
129 A Systematic Review of Cardiogenic Shock in the Setting of Severe Aortic Stenosis: Prevalence, Management and Outcomes Mohammed Essa, Ehimen Aneni, Cecilia Bernardi, James Fleming, Maria Paredes, Katherine Frumento, Medhat Abdelmessih, Lissa Sugeng, Lavanya Bellumkonda; Yale School of Medicine, New Haven, CT Background: Cardiogenic shock (CS) management has evolved over the recent years especially after the development of mechanical circulatory support devices (MCS). Aortic stenosis (AS) is the most common valvular heart disease, yet little is known about the prevalence, management, and mortality of the AS and CS combination. Methods: A systematic search was conducted to identify studies that included patients with combined AS and CS using EMBASE, MEDLINE, and Scopus. Primary outcomes included in-hospital, 30-day, and 1-year mortality. Additional outcomes included procedure-related complications. The study protocol was registered at PROSPERO (CRD42018112245). Results: A total of 10 studies representing 338 patients were included. Prevalence of AS presenting with CS ranged from 3.5% to 12%. In-hospital mortality ranged from 43% to 77% in patients treated with Balloon Aortic Valvuloplasty (BAV), 0% and 11% in patients who underwent surgical valve replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR) respectively. In patients undergoing BAV, 30-day mortality varied between 50% and 55%, and between 19% and 33% in those treated with TAVR. Delaying valve intervention for more than 48 hours was found to negatively impact survival after BAV. There was limited evidence on the use of Mechanical Circulatory Support (MCS). Conclusion: AS presenting with CS is a fatal condition with no clarity of management strategy. Time to intervention on the valve is critical. Valve replacement through either SAVR or TAVR had better outcomes compared to BAV alone. There is limited evidence on MCS as a management strategy in patients with AS complicated by CS.
130 Association between Left Ventricular Ejection Fraction and Worsening Renal Function in Acute Heart Failure: Insights from the RELAX-AHF-2 Trial Siting Feng, Satit Janwanishstaporn, John R. Teerlink, Marco Cotter G. Metra, Beth A. Davison, G. Michael Felker, Gerasimos Filippatos, Peter S. Pang, Piotr Ponikowski, Thomas Severin, Claudio Gimpelewicz, I.E. Sama, Adriaan A. Voors, Barry H. Greenberg; University of California San Diego, San Diego, CA
131 Relationship between “Dry Weight” and Actual Weight Loss in Patients Hospitalized for Heart Failure J. Fleming, M. Griffin, J. Ivey-Miranda, P. Raghavendra, G. Struyk, P. Shamlian, N. Gomez, J. Barnett, B. Stewart, E. Wycallis, A. Thomas, D. Mahoney, M. Pattoli, V. Rao, J. Testani; Yale University School of Medicine, New Haven, CT Introduction: In the treatment of patients with acute decompensated heart failure (ADHF) estimation of the degree of volume overload is critical in guiding the goals of diuretic therapy. A “dry weight,” or the weight of a patient when they are euvolemic, is commonly used by clinicians to determine when to discontinue diuretic therapy during hospitalization. However, it is unclear how this dry weight relates to the actual weight loss achieved during hospitalization. Hypothesis: Dry weight will have limited correlation with the ultimate weight loss achieved during hospitalization. Methods: Patients hospitalized for ADHF with volume overload and receiving IV diuretics were enrolled. Each participant completed a clinical assessment survey that asked, “How many pounds of water weight are you above your dry weight?” We additionally extracted any dry weight that was documented in the electronic medical record (EMR) and the lowest documented weight in the EMR within the previous year. The primary comparison was to evaluate the correlation between the patients’