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Effects of Ultrafiltration on Renal Function in Treatment of Patients with Acute Decompensated Heart Failure: A Meta-Analysis
The 12th Annual Scientific Meeting
292 Use of the Symptom Interactional Framework To Examine the Multidimensional Domains of Fatigue and Depression in Heart Failure Patients Rebecca A. Gary1, Sandra B. Dunbar1, Dominique L. Musselman2, Elaine M. Cress3, Melinda K. Higgins1; 1School of Nursing, Emory University, Atlanta, GA; 2School of Medicine, Emory University, Atlanta, GA; 3Kinesiology, University of Georgia, Athens, GA Aims: Fatigue and depression are common in patients with heart failure (HF), but little is known about the underlying interactions. This study used the Symptom Interactional Framework (SIF) to examine the multidimensional relationships and predictors of fatigue in HF patients diagnosed with depression. Methods: 74 NYHA class II-III HF patients who were diagnosed with depression using Hamilton Rating Scale for Depression (HAM-D) (mean 15.9 6 4.3) participated. The mean age was 65.8 6 13.5 years, 57% were NYHA class III, 72% were Caucasian, and 57% were female. The vitality subscale of the Medical Outcomes Study short form 36 (SFe36) was used to measure fatigue. Physiological (tumor necrosis alpha [TNF-alpha], Continuous Scale Physical Function Teste10 item [CSPFPe10]), psychological (Minnesota Living with Heart Failure Questionnaire [MLHFQ]); behavioral (alcohol and smoking history, anxiety and depression medication use); and sociocultural (race, educational, marital status) domains and measures were included in the model. Descriptive statistics, Pearson’s r correlation coefficients and a multivariate linear regression model were used to analyze the relationships among the variables controlling for age, gender, comorbidities (Charlson comorbidity), LVEF and NYHA class. Results: A mean vitality score of 37.9 6 9.9 indicated a high perceived fatigue level. No socio-cultural variables were correlated with fatigue. Behavioral domain variables significantly associated with fatigue included antidepressant use (r 5 0.25, p!.05) and smoking history (r5.26, p!.05). A significant negative relationship between fatigue and the psychological domain factor QOL (r5 -.50, p!.01) was found. When the SIF variables were entered into a regression model, physiological (TNF alpha [t5 e2.4, p! .02], psychological (MLHFQ [t5 e3.34, p! .002]), and behavioral (antidepressant use [t5 2.1, p! .042 ] factors predicted 33% of the variance of fatigue (adjusted r2 5 .33). Conclusions: The SIF is a potentially useful interdisciplinary model for studying symptom interactions in HF patients, and the association of the domain variables with fatigue with depression warrants further study. A greater understanding of the underlying mechanisms of fatigue and other symptom interactions will facilitate targeting more effective symptom management in the future.
HFSA
S91
Conclusions: Ultrafiltration leads to a modest increase in serum creatinine in acute decompensated heart failure patients with compromised renal function. Acute kidney injury is an independent predictor of mortality in patients. It is beleived that ultrafiltration could also have a renal protective effect and might restore responsiveness to diuretics. It is not known if this increase in serum creatinine has an impact on mortality. Randomized controlled studies with long-term follow-up are required to assess the benefits of UF in renal failure patients with acute decompensated heart failure.
294 Isosorbide Dinitrate and Hydralazine as Add-On Therapy in Patients Admitted with Advanced Decompensated Heart Failure Wilfried Mullens1, Zuheir Abrahams1, Gary S. Francis1, George Sokos1, Randall C. Starling1, James B. Young1, David O. Taylor1, Wilson H.W. Tang1; 1Cleveland Clinic, Cleveland, OH Background: Data supporting the use of oral isosorbide dinitrate and/or hydralazine (I/H) as add-on therapy to standard neurohormonal antagonists in advanced chronic heart failure are limited, especially in the non-African American population. Methods: We reviewed consecutive patients with advanced decompensated heart failure admitted between 2003e6 with a cardiac index # 2.2 L/min/m2 admitted for intensive medical therapy. Patients discharged with angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) (control group) were compared with those receiving I/H plus ACE-I/ARB and I/H (I/H group). Results: The control (n 5 97) and I/H (n 5 142) groups had similar demographic characteristics (20% African-American), blood pressure, and renal function. Patients in the I/H group had a significantly higher estimated systemic vascular resistance (SVR: 1,660 versus 1,452 dynes/cm5, p ! 0.001) and lower cardiac index (1.7 versus 1.9 l/min.m2, p ! 0.001) on admission. The I/H group achieved a similar reduction in intra-cardiac filling pressures and discharge blood pressures than controls, but had greater improvement in cardiac index and SVR. Use of I/H was associated with lower rate of all-cause mortality (34% versus 41%; OR: 0.65; 95% CI 0.43e0.99; p 5 0.04) and all-cause mortality / heart failure re-hospitalization (70% versus 85%; OR: 0.72; 95% CI 0.54e0.97; p 5 0.03) without increase in cardiac transplantation (22% versus 19%; p5ns), and irrespective of race.
293 Effects of Ultrafiltration on Renal Function in Treatment of Patients with Acute Decompensated Heart Failure: A Meta-Analysis Nishant B. Jalandhara1,2, Saravanan Balamuthusamy1,2, Khosla Sandeep1, Priyanka B. Jalandhara1; 1Division of Cardiology, Mt Sinai Hospital, Chicago, IL; 2Division of Cardiology, North Chicago VA Medical Center, North Chicago, IL Background: In the United States, 1 million hospitalizations are attributed primarily to heart failure. The congestive symptoms of heart failure are primarily due to fluid retention because of compromised hemodynamics and neurohumoral balance. The current ACC/AHA guidelines recommend the use of ultrafiltration if the degree of renal dysfunction is severe or if the edema becomes resistant to medical treatment. Objectives: Ultrafiltration has been shown to improve symptoms and decrease sympathetic drive in patients with decompensated heart failure. However, volume removal might have adverse effects on renal function. We have assessed the effect on renal function when patients with Acute Decompensated Heart Failure were treated with Ultrafiltration. Methods: Randomized control trials that included Acute Decompensated Heart Failure patients with renal insufficiency in which Ultrafiltration was used alone or compared with conventional therapy were included for the meta-analysis. Systematic review of literature was performed with relevant terms in MEDLINE and OVID search engines and statistics was computed with MantelHaenszel statistics. Results: Five trials (N 5 344) fulfilled the inclusion criteria for the study. There is a significant increase in the serum creatinine 0.52 (0.62e0.41: p ! 0.18) from baseline when compared to the post treatment creatinine measured after the initiation of Ultrafiltration but this result are not statistically significant.
Conclusions: In patients admitted with advanced decompensated heart failure, the addition of isosorbide dinatrate/hydralazine to neurohormonal blockade according to a standardized titration protocol is associated with favorable hemodynamic profile and long-term clinical outcomes.
295 Worsening Renal Function in Patients Admitted with Acute Decompensated Heart Failure: Incidence, Predictors and Prognostic Value Cesar A. Belziti1, Ledezma Paola1, Bagnati P. Rodrigo1, Vulcano Norberto1, Fernandez Sandra1; 1Heart Failure UInit - Cardiology, Hospital Italiano, Buenos Aires, Argentina Background: acute decompensated heart failure (ADHF) is associated with an increased risk for development of worsening renal function (WRF), prolonged hospitalization and worse prognosis. Objectives: to assess the incidence and predictors of WRF and its one-year prognostic significance in patients admitted in the Coronary Care Unit for ADHF. Methods: the clinical data of 200 consecutively patients admitted with ADHF were prospectively collected. To correct for the influence of baseline seric creatinine (s-Cr) WRF was defined as the occurrence, at any time during hospitalization, of both a $ 0.3 mg/dL and a $25% increase in s-Cr from admission Results: 43 % were women, mean age 78 years, 51% had preserved left ventricular function (ejection fraction O50 %), 38 % ischemic etiology, 21 % atrial fibrillation and 24% diabetes. Mean s-Cr was 1.57 6 0.6 mg/dL and mean glomerular filtration rate (GFR) calculated by the abbreviated MDRD formula was 59.5 ml/min/1.73 m2. Forty-six patients (23%) developed WRF. In multivariate analysis patients older than 80 years (OR: 1.4, 95% CI: 1.1e1.9), baseline GFR !60 mL/min/1.73 m2 (OR: 1.6, 95% CI: 1.1e1.8) and systolic arterial pressure lower than 90 mmHg (OR: 1.7, 95%, CI: 1.2e2.0) on admission emerged as independent predictors of WRF (p ! 0.05). Median length of stay was 9 days (IQR 6e16 days) for patients who developed WRF and 4 days (IQR 2e8 days) for patients without WRF (p ! 0.05). The cumulative rate of one-year death and HF readmission by Kaplan- Meier method was 36% for the whole group, 45% for patients with WRF and 29% for patients without WRF (p ! 0.05). Conclusions: WRF is a frequent complication in patients hospitalized for
292 Use of the Symptom Interactional Framework To Examine the Multidimensional Domains of Fatigue and Depression in Heart Failure Patients Rebecca A. Gary1, Sandra B. Dunbar1, Dominique L. Musselman2, Elaine M. Cress3, Melinda K. Higgins1; 1School of Nursing, Emory University, Atlanta, GA; 2School of Medicine, Emory University, Atlanta, GA; 3Kinesiology, University of Georgia, Athens, GA Aims: Fatigue and depression are common in patients with heart failure (HF), but little is known about the underlying interactions. This study used the Symptom Interactional Framework (SIF) to examine the multidimensional relationships and predictors of fatigue in HF patients diagnosed with depression. Methods: 74 NYHA class II-III HF patients who were diagnosed with depression using Hamilton Rating Scale for Depression (HAM-D) (mean 15.9 6 4.3) participated. The mean age was 65.8 6 13.5 years, 57% were NYHA class III, 72% were Caucasian, and 57% were female. The vitality subscale of the Medical Outcomes Study short form 36 (SFe36) was used to measure fatigue. Physiological (tumor necrosis alpha [TNF-alpha], Continuous Scale Physical Function Teste10 item [CSPFPe10]), psychological (Minnesota Living with Heart Failure Questionnaire [MLHFQ]); behavioral (alcohol and smoking history, anxiety and depression medication use); and sociocultural (race, educational, marital status) domains and measures were included in the model. Descriptive statistics, Pearson’s r correlation coefficients and a multivariate linear regression model were used to analyze the relationships among the variables controlling for age, gender, comorbidities (Charlson comorbidity), LVEF and NYHA class. Results: A mean vitality score of 37.9 6 9.9 indicated a high perceived fatigue level. No socio-cultural variables were correlated with fatigue. Behavioral domain variables significantly associated with fatigue included antidepressant use (r 5 0.25, p!.05) and smoking history (r5.26, p!.05). A significant negative relationship between fatigue and the psychological domain factor QOL (r5 -.50, p!.01) was found. When the SIF variables were entered into a regression model, physiological (TNF alpha [t5 e2.4, p! .02], psychological (MLHFQ [t5 e3.34, p! .002]), and behavioral (antidepressant use [t5 2.1, p! .042 ] factors predicted 33% of the variance of fatigue (adjusted r2 5 .33). Conclusions: The SIF is a potentially useful interdisciplinary model for studying symptom interactions in HF patients, and the association of the domain variables with fatigue with depression warrants further study. A greater understanding of the underlying mechanisms of fatigue and other symptom interactions will facilitate targeting more effective symptom management in the future.
HFSA
S91
Conclusions: Ultrafiltration leads to a modest increase in serum creatinine in acute decompensated heart failure patients with compromised renal function. Acute kidney injury is an independent predictor of mortality in patients. It is beleived that ultrafiltration could also have a renal protective effect and might restore responsiveness to diuretics. It is not known if this increase in serum creatinine has an impact on mortality. Randomized controlled studies with long-term follow-up are required to assess the benefits of UF in renal failure patients with acute decompensated heart failure.
294 Isosorbide Dinitrate and Hydralazine as Add-On Therapy in Patients Admitted with Advanced Decompensated Heart Failure Wilfried Mullens1, Zuheir Abrahams1, Gary S. Francis1, George Sokos1, Randall C. Starling1, James B. Young1, David O. Taylor1, Wilson H.W. Tang1; 1Cleveland Clinic, Cleveland, OH Background: Data supporting the use of oral isosorbide dinitrate and/or hydralazine (I/H) as add-on therapy to standard neurohormonal antagonists in advanced chronic heart failure are limited, especially in the non-African American population. Methods: We reviewed consecutive patients with advanced decompensated heart failure admitted between 2003e6 with a cardiac index # 2.2 L/min/m2 admitted for intensive medical therapy. Patients discharged with angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) (control group) were compared with those receiving I/H plus ACE-I/ARB and I/H (I/H group). Results: The control (n 5 97) and I/H (n 5 142) groups had similar demographic characteristics (20% African-American), blood pressure, and renal function. Patients in the I/H group had a significantly higher estimated systemic vascular resistance (SVR: 1,660 versus 1,452 dynes/cm5, p ! 0.001) and lower cardiac index (1.7 versus 1.9 l/min.m2, p ! 0.001) on admission. The I/H group achieved a similar reduction in intra-cardiac filling pressures and discharge blood pressures than controls, but had greater improvement in cardiac index and SVR. Use of I/H was associated with lower rate of all-cause mortality (34% versus 41%; OR: 0.65; 95% CI 0.43e0.99; p 5 0.04) and all-cause mortality / heart failure re-hospitalization (70% versus 85%; OR: 0.72; 95% CI 0.54e0.97; p 5 0.03) without increase in cardiac transplantation (22% versus 19%; p5ns), and irrespective of race.
293 Effects of Ultrafiltration on Renal Function in Treatment of Patients with Acute Decompensated Heart Failure: A Meta-Analysis Nishant B. Jalandhara1,2, Saravanan Balamuthusamy1,2, Khosla Sandeep1, Priyanka B. Jalandhara1; 1Division of Cardiology, Mt Sinai Hospital, Chicago, IL; 2Division of Cardiology, North Chicago VA Medical Center, North Chicago, IL Background: In the United States, 1 million hospitalizations are attributed primarily to heart failure. The congestive symptoms of heart failure are primarily due to fluid retention because of compromised hemodynamics and neurohumoral balance. The current ACC/AHA guidelines recommend the use of ultrafiltration if the degree of renal dysfunction is severe or if the edema becomes resistant to medical treatment. Objectives: Ultrafiltration has been shown to improve symptoms and decrease sympathetic drive in patients with decompensated heart failure. However, volume removal might have adverse effects on renal function. We have assessed the effect on renal function when patients with Acute Decompensated Heart Failure were treated with Ultrafiltration. Methods: Randomized control trials that included Acute Decompensated Heart Failure patients with renal insufficiency in which Ultrafiltration was used alone or compared with conventional therapy were included for the meta-analysis. Systematic review of literature was performed with relevant terms in MEDLINE and OVID search engines and statistics was computed with MantelHaenszel statistics. Results: Five trials (N 5 344) fulfilled the inclusion criteria for the study. There is a significant increase in the serum creatinine 0.52 (0.62e0.41: p ! 0.18) from baseline when compared to the post treatment creatinine measured after the initiation of Ultrafiltration but this result are not statistically significant.
Conclusions: In patients admitted with advanced decompensated heart failure, the addition of isosorbide dinatrate/hydralazine to neurohormonal blockade according to a standardized titration protocol is associated with favorable hemodynamic profile and long-term clinical outcomes.
295 Worsening Renal Function in Patients Admitted with Acute Decompensated Heart Failure: Incidence, Predictors and Prognostic Value Cesar A. Belziti1, Ledezma Paola1, Bagnati P. Rodrigo1, Vulcano Norberto1, Fernandez Sandra1; 1Heart Failure UInit - Cardiology, Hospital Italiano, Buenos Aires, Argentina Background: acute decompensated heart failure (ADHF) is associated with an increased risk for development of worsening renal function (WRF), prolonged hospitalization and worse prognosis. Objectives: to assess the incidence and predictors of WRF and its one-year prognostic significance in patients admitted in the Coronary Care Unit for ADHF. Methods: the clinical data of 200 consecutively patients admitted with ADHF were prospectively collected. To correct for the influence of baseline seric creatinine (s-Cr) WRF was defined as the occurrence, at any time during hospitalization, of both a $ 0.3 mg/dL and a $25% increase in s-Cr from admission Results: 43 % were women, mean age 78 years, 51% had preserved left ventricular function (ejection fraction O50 %), 38 % ischemic etiology, 21 % atrial fibrillation and 24% diabetes. Mean s-Cr was 1.57 6 0.6 mg/dL and mean glomerular filtration rate (GFR) calculated by the abbreviated MDRD formula was 59.5 ml/min/1.73 m2. Forty-six patients (23%) developed WRF. In multivariate analysis patients older than 80 years (OR: 1.4, 95% CI: 1.1e1.9), baseline GFR !60 mL/min/1.73 m2 (OR: 1.6, 95% CI: 1.1e1.8) and systolic arterial pressure lower than 90 mmHg (OR: 1.7, 95%, CI: 1.2e2.0) on admission emerged as independent predictors of WRF (p ! 0.05). Median length of stay was 9 days (IQR 6e16 days) for patients who developed WRF and 4 days (IQR 2e8 days) for patients without WRF (p ! 0.05). The cumulative rate of one-year death and HF readmission by Kaplan- Meier method was 36% for the whole group, 45% for patients with WRF and 29% for patients without WRF (p ! 0.05). Conclusions: WRF is a frequent complication in patients hospitalized for