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Rapid Shallow Breathing Worsens Prior to Heart Failure Decompensation
S14 Journal of Cardiac Failure Vol. 20 No. 8S August 2014 (aged 67610 years, n514 HFpEF, n512 control) underwent right heart catheterization at rest, during supine exercise, and with acute saline loading in a prospective study. Exercise and saline each increased cardiac output (CO) and pressures in the right atrium (RAP), pulmonary artery (PAP), and pulmonary capillary wedge positions (PCWP). However, the magnitudes of change were much greater with exercise compared to saline for mean PAP (+1769 vs +865 mmHg; p!0.0001), PCWP (+1368 vs +964mmHg; p50.01) and CO (+5.162.7 vs +1.861.3 L/min; p! 0.0001). These differential responses were restricted to the HFpEF group, who experienced w2-fold greater increases in PCWP with exercise compared to saline (+1865 vs +1064; p50.0002, Figure), in contrast to controls where changes in PCWP were similar with the two stresses (+664 vs +764mmHg, p50.46, Figure). The slope of increase in PCWP relative to the volume of saline infused was similar in HFpEF and controls (+23610 vs +1768 mmHg/ml/m2, p50.11) whereas the slope of increase in PCWP from baseline to 20-Watts exercise was 3-fold steeper in HFpEF compared to controls (+0.860.3 vs +0.362 mmHg/Watt; p!0.0001). Conclusions: Exercise elicits greater PCWP elevation compared to saline in HFpEF but not controls, suggesting that hemodynamic stresses beyond passive stiffness and increased venous return explain the development of exertional pulmonary venous hypertension in HFpEF. Saline loading is less sensitive than exercise to detect hemodynamic abnormalities diagnostic of HFpEF.
implanted devices, have demonstrated changes leading to admissions. Since patients often present with rapid shallow breathing, we hypothesize that a rapid shallow breathing index (RSBI) will better reflect respiratory distress than either RR or MV. Method: Multisensor Chronic Evaluations in Ambulatory Heart Failure Patients Study (MultiSENSE) enrolled patients implanted with COGNISÒ (Boston Scientific, St Paul, MN, USA) cardiac resynchronization therapy defibrillators. The device was reprogrammed to trend RR and relative tidal volume (rTV) from transthoracic impedance. Relative MV (rMV) and RSBI were calculated as rMV 5 RRrTV and RSBI 5 RR/rTV respectively. HF events (HFEs) were defined as HF admissions or unscheduled visits with intravenous HF treatment. All HFEs were adjudicated. For each HFE, the average of a 7-day pre-event period (Evt) and a baseline period (BL, 35 to 63 days pre-event) were calculated. Percentage change (% chg 5 [EvtBL]/BL) was determined for each event. The mean % chg was tested against 0 using paired t-test (p!0.05). Results: Fifty-two of the 528 patients enrolled (age 66.4610.8, 72.7% male, ejection fraction 29.3611.5%) experienced 69 HFEs. Daily mean RR was elevated significantly prior to HFEs (2.2%, p50.03) while daily mean rTV and rMV did not change significantly (-1.5% and 0.6% respectively). Daily RSBI showed the largest change among all respiratory parameters, and increased by 6.0% (p50.01). Conclusion: Data from MultiSENSE study showed that rapid shallow breathing measured by RR and RSBI changed significantly before HF events, suggesting that these measures might be useful in early identification of worsening heart failure status.
037 Transient and Persistent Worsening Renal Function during Acute Heart Failure Hospitalization: Insights from the ADHERE Registry Linked to Medicare Claims Arun Krishnamoorthy1,2, Melissa A. Greiner2, Puza P. Sharma3, Laura G. Qualls2, Adam D. DeVore1,2, Katherine Waltman Johnson3, Gregg C. Fonarow4, Lesley H. Curtis2, Adrian F. Hernandez1,2; 1Duke University School of Medicine, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Novartis Pharmaceuticals Corporation, East Hanover, NJ; 4Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA Background: Worsening renal function (WRF) occurs often during hospitalization for acute heart failure (AHF) and is associated with poor clinical outcomes. Transient and persistent WRF may be associated with differing risks. Methods: AHF patients age $ 65 were identified between 2003 and 2006 from the ADHERE Registry linked to Medicare claims. WRF was defined as any increase in serum creatinine $ 0.3 mg/ dL from admission. Patients with WRF were classified by the difference between last recorded and admission creatinine into either transient (! 0.3 mg/dL) or persistent ($ 0.3 mg/dL) WRF. We examined the unadjusted rates and adjusted associations between 90-day outcomes and the following groups: no WRF, transient WRF, and persistent WRF. Results: Among 27,309 patients, 18,568 (68.0%) had no WRF, 3,205 (11.7%) had transient WRF and 5,536 (20.3%) had persistent WRF. Compared with no WRF, patients with either transient or persistent WRF had higher observed rates of 90-day post discharge all-cause readmission and 90-day post admission mortality (p ! 0.001; Figure). In adjusted analyses, transient and persistent WRF were each associated compared with no WRF with a higher risk of 90-day post admission mortality (p ! 0.001); no significant risk differences were found for 90-day post discharge all-cause or HF readmission. Persistent WRF when compared with transient WRF was associated with a higher risk of 90-day post admission mortality (hazard ratio (HR) 1.46, 99% confidence interval (CI) 1.28-1.66, p ! 0.001). Conclusion: Transient and persistent WRF during AHF were each associated with a higher adjusted 90-day risk for all-cause mortality post admission, with worse outcomes for those with persistent WRF. There is an important need to identify therapies that prevent WRF.
Figure.
039 Distal Tubular Compensation as an Important Mechanistic Site of Diuretic Resistance in Heart Failure Olga Laur1, Veena S. Rao1, Susan J. Cheng1, Alexander J. Kula1, Lavanya Bellumkonda1, Wilson W.H. Tang2, Chirag R. Parikh1, Jeffrey M. Testani1; 1Yale School of Medicine, New Haven, CT; 2Cleveland Clinic, Cleveland, OH Background: Little is known about the mechanisms underlying loop diuretic resistance (DR) in heart failure (HF). Specifically, it is unclear if DR is primarily the result of resistance at the sight of tubular action in the loop of Henle, or whether it is mainly due to downstream compensatory sodium reabsorption in the distal tubule. Defining the mechanism of DR could guide therapy since treatment options differ substantially based on tubular location of resistance. Methods: 32 HF patients receiving loop diuretics were enrolled. Diuretic efficiency served as the primary metric of diuretic resistance and was calculated as ml of urine per 40 mg of IV furosemide equivalents. The urinary fractional excretion of endogenous lithium (FeLi) was used as a wellvalidated metric of proximal tubular/loop of Henle sodium handling, and the relative
Figure. Cumulative incidence of mortality and all cause readmission.
038 Rapid Shallow Breathing Worsens Prior to Heart Failure Decompensation Alessandro Capucci1, Giulio Molon2, Michael R. Gold3, Yi Zhang4, Robert Sweeney4, Viktoria Averina4, John P. Boehmer5; 1Universita Politecnica delle Marche, Ancona, Italy; 2Sacro Cuore Hospital, Negrar, Italy; 3Medical University of South Carolina, Charleston, SC; 4Boston Scientific, St Paul, MN; 5Penn State Milton S. Hershey Medical Center, Hershey, PA Introduction: Respiratory distress is one of the primary drivers for heart failure (HF) hospitalization. Respiratory rate (RR) and minute ventilation (MV), as monitored by
Figure.
implanted devices, have demonstrated changes leading to admissions. Since patients often present with rapid shallow breathing, we hypothesize that a rapid shallow breathing index (RSBI) will better reflect respiratory distress than either RR or MV. Method: Multisensor Chronic Evaluations in Ambulatory Heart Failure Patients Study (MultiSENSE) enrolled patients implanted with COGNISÒ (Boston Scientific, St Paul, MN, USA) cardiac resynchronization therapy defibrillators. The device was reprogrammed to trend RR and relative tidal volume (rTV) from transthoracic impedance. Relative MV (rMV) and RSBI were calculated as rMV 5 RRrTV and RSBI 5 RR/rTV respectively. HF events (HFEs) were defined as HF admissions or unscheduled visits with intravenous HF treatment. All HFEs were adjudicated. For each HFE, the average of a 7-day pre-event period (Evt) and a baseline period (BL, 35 to 63 days pre-event) were calculated. Percentage change (% chg 5 [EvtBL]/BL) was determined for each event. The mean % chg was tested against 0 using paired t-test (p!0.05). Results: Fifty-two of the 528 patients enrolled (age 66.4610.8, 72.7% male, ejection fraction 29.3611.5%) experienced 69 HFEs. Daily mean RR was elevated significantly prior to HFEs (2.2%, p50.03) while daily mean rTV and rMV did not change significantly (-1.5% and 0.6% respectively). Daily RSBI showed the largest change among all respiratory parameters, and increased by 6.0% (p50.01). Conclusion: Data from MultiSENSE study showed that rapid shallow breathing measured by RR and RSBI changed significantly before HF events, suggesting that these measures might be useful in early identification of worsening heart failure status.
037 Transient and Persistent Worsening Renal Function during Acute Heart Failure Hospitalization: Insights from the ADHERE Registry Linked to Medicare Claims Arun Krishnamoorthy1,2, Melissa A. Greiner2, Puza P. Sharma3, Laura G. Qualls2, Adam D. DeVore1,2, Katherine Waltman Johnson3, Gregg C. Fonarow4, Lesley H. Curtis2, Adrian F. Hernandez1,2; 1Duke University School of Medicine, Durham, NC; 2Duke Clinical Research Institute, Durham, NC; 3Novartis Pharmaceuticals Corporation, East Hanover, NJ; 4Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA Background: Worsening renal function (WRF) occurs often during hospitalization for acute heart failure (AHF) and is associated with poor clinical outcomes. Transient and persistent WRF may be associated with differing risks. Methods: AHF patients age $ 65 were identified between 2003 and 2006 from the ADHERE Registry linked to Medicare claims. WRF was defined as any increase in serum creatinine $ 0.3 mg/ dL from admission. Patients with WRF were classified by the difference between last recorded and admission creatinine into either transient (! 0.3 mg/dL) or persistent ($ 0.3 mg/dL) WRF. We examined the unadjusted rates and adjusted associations between 90-day outcomes and the following groups: no WRF, transient WRF, and persistent WRF. Results: Among 27,309 patients, 18,568 (68.0%) had no WRF, 3,205 (11.7%) had transient WRF and 5,536 (20.3%) had persistent WRF. Compared with no WRF, patients with either transient or persistent WRF had higher observed rates of 90-day post discharge all-cause readmission and 90-day post admission mortality (p ! 0.001; Figure). In adjusted analyses, transient and persistent WRF were each associated compared with no WRF with a higher risk of 90-day post admission mortality (p ! 0.001); no significant risk differences were found for 90-day post discharge all-cause or HF readmission. Persistent WRF when compared with transient WRF was associated with a higher risk of 90-day post admission mortality (hazard ratio (HR) 1.46, 99% confidence interval (CI) 1.28-1.66, p ! 0.001). Conclusion: Transient and persistent WRF during AHF were each associated with a higher adjusted 90-day risk for all-cause mortality post admission, with worse outcomes for those with persistent WRF. There is an important need to identify therapies that prevent WRF.
Figure.
039 Distal Tubular Compensation as an Important Mechanistic Site of Diuretic Resistance in Heart Failure Olga Laur1, Veena S. Rao1, Susan J. Cheng1, Alexander J. Kula1, Lavanya Bellumkonda1, Wilson W.H. Tang2, Chirag R. Parikh1, Jeffrey M. Testani1; 1Yale School of Medicine, New Haven, CT; 2Cleveland Clinic, Cleveland, OH Background: Little is known about the mechanisms underlying loop diuretic resistance (DR) in heart failure (HF). Specifically, it is unclear if DR is primarily the result of resistance at the sight of tubular action in the loop of Henle, or whether it is mainly due to downstream compensatory sodium reabsorption in the distal tubule. Defining the mechanism of DR could guide therapy since treatment options differ substantially based on tubular location of resistance. Methods: 32 HF patients receiving loop diuretics were enrolled. Diuretic efficiency served as the primary metric of diuretic resistance and was calculated as ml of urine per 40 mg of IV furosemide equivalents. The urinary fractional excretion of endogenous lithium (FeLi) was used as a wellvalidated metric of proximal tubular/loop of Henle sodium handling, and the relative
Figure. Cumulative incidence of mortality and all cause readmission.
038 Rapid Shallow Breathing Worsens Prior to Heart Failure Decompensation Alessandro Capucci1, Giulio Molon2, Michael R. Gold3, Yi Zhang4, Robert Sweeney4, Viktoria Averina4, John P. Boehmer5; 1Universita Politecnica delle Marche, Ancona, Italy; 2Sacro Cuore Hospital, Negrar, Italy; 3Medical University of South Carolina, Charleston, SC; 4Boston Scientific, St Paul, MN; 5Penn State Milton S. Hershey Medical Center, Hershey, PA Introduction: Respiratory distress is one of the primary drivers for heart failure (HF) hospitalization. Respiratory rate (RR) and minute ventilation (MV), as monitored by
Figure.