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Renal Function in Patients With Acute Decompensated Heart Failure Treated With Ultrafiltration
S74 Journal of Cardiac Failure Vol. 18 No. 8S August 2012 Whether this relationship holds true in patients hospitalized with HF and differs between those in sinus rhythm (SR) and in those with atrial fibrillation (AF) has not been well studied. Methods: We examined 145,211 admissions for HF from 295 hospitals enrolled in Get With The Guidelines-Heart Failure (GWTG-HF) from January 2005 through September 2011. We evaluated the association of admission HR to in-hospital outcomes, overall and for patients in AF (n535,636) and SR (n577,850). Results: The median admission HR was 82 (IQR 70-97) overall, 82 (70-96) for SR and 82 (71-100) for AF. Patients presenting at higher HR tended to be younger, have less comorbidities, and lower LVEF. In-hospital mortality was 3.1%. Mortality had a J-shaped relationship with HR, with the lowest mortality rate between 60-80bpm (Figure). However, the relationship of mortality and HR differed between patients presenting in SR versus AF: at HR above 100bpm, the mortality curve for AF plateaued, whereas that for patients in SR continued to rise. Higher HR was associated with higher mortality (adjusted odds ratio [aOR] 1.26, 95% CI 1.22-1.31 per 10bpm increase in HR), longer length of stay (aOR 1.10, 95% CI 1.09-1.12 for LOS O4days), and greater likelihood of being discharged to other than home (aOR 1.09, 95% CI 1.07-1.10). Conclusions: Higher admission HR is independently associated with worse outcomes, including increased mortality, in patients admitted for HF. However, the slope of this relationship is different at higher HRs between patients in SR and AF. Whether early reduction in HR will improve short-term outcomes in patients hospitalized with HF is worthy of investigation.
238 Improved Physical Function Confers Greater Quality of Life Benefits for NYHA Class III Than for NYHA Class II Patients Rebecca Gary1, Melinda Higgins1, Elaine Cress2, Andrew Smith3, Sandra Dunbar1; 1 Nursing, Emory University, Atlanta, GA; 2Kinesiology, University of Georgia, Athens, GA; 3Medicine, Emory University, Atlanta, GA Background: Heart failure results in a progressive decline in physical functioning and lowers quality of life (QOL) which has been shown to improve with exercise in some studies. Few studies have investigated whether improved functional performance also leads patients to report a better quality of life. We hypothesized that patients with HF who were more symptomatic and physically limited (NYHA class III) enrolled in a 12 week home based exercise program would have the most significant improvement in physical function and HRQOL than less compromised patients (NYHA class II) and controls. Methods: Patients were randomized to exercise (N540) or to a psycho-educational control group (N536). Continuous Scale Physical Function Performance test (CS-PFP10) that simulates daily household tasks (i.e., sweeping, laundry tasks, grocery carry), and QOL (Minnesota Living with Heart Failure Questionnaire [MLHFQ]) were evaluated at baseline (T1) and at 12-weeks (T2). Descriptive statistics, t-tests and linear regression models were used to analyze differences between groups. Results: Seventy-six NYHA II-III HF patients (mean age 63.9 6 12.4) participated; 51% were NYHA class III, 62% were Caucasian, and 59% were female. NYHA class III participants had significantly lower CS-PFP10 (31.7 6 14.9 vs. 45.8 6 15.9, p!0.001) and poorer QOL (43.4 6 24.9 vs 33.9 6 22.4, p50.085) than NYHA class II participants, respectively. After adjusting for baseline, T2 changes in CS-PFP10 scores (t 5 -3.9, p! 0.001) predicted better MLHFQ scores among NYHA class III participants (t 5 -3.7, p! 0.001) compared to NYHA class II participants (t5 -1.9, p!0.06). The association between change in CS-PFP10 and MLHFQ was stronger for NYHA class III (r50.36) than class II (r50.15) patients. In addition, the change in CS-PFP10 (5.1 vs 4.1 vs 1.2) and MLHFQ (-13.4 vs -6.6 vs -2.5) scores were greater among NYHA class III exercise participants than in NYHA class II exercise or control participants. Conclusions: Quality of life was improved subsequent to increased functional performance after 3 months of exercise in patients with Class II and III HF patients, with more impairment (Class III) reflecting greatest improvement. Functional performance tests that simulate daily household tasks may provide HF patients with a tangible measure of how exercise improves routine activities which in turn may translate into better QOL.
239 Renal Function in Patients With Acute Decompensated Heart Failure Treated With Ultrafiltration Nicholas Haglund1, Michael Johnston1, Ioana Dumitru1, Joan Mack2, Brian Lowes1, Eugenia Raichlin1; 1Cardiology, University of Nebraska Medical Center, Omaha, NE; 2Department of Nursing, University of Nebraska Medical Center, Omaha, NE
Fig. 1. In hospital death rates by heart failure, for all admissions for HF (top) and dichotomized by heart rhythm (sinus rhythm versus arterial fibrillation) (bottom). Loess plots with data density shown by vertical marks
Background: Ultrafiltration (UF) is used to treat patients with diuretic-resistant, acute decompensated heart failure (ADHF); however worsening renal function (WRF) is a common complication. The aim of the study was to identify clinical and echocardiographic predictors of WRF and effect on clinical outcomes in patients with ADHF treated with UF. Methods: From 1/2008 to 12/2011, 100 patients (age 64614 years, 61 % men) underwent UF at the University of Nebraska Medical Center. WRF was defined as a rise in serum creatinine level O 0.3 mg/ dl. Patients were divided into WRF and control groups based on changes in serum creatinine during UF. All patients were on optimal medical HF therapy. Average dose of intravenous furosemide before UF was 217 6 212 mg/day. Results: In the whole study population, creatinine increased from 1.960.7 mg/ dL to 2.0 6 1.1 mg/dL, (p,! 0.001) and WRF developed in 40 (40%) of patients. The peak UF rate (175672mL/h vs. 141 649mL/h, p5 0.01) was higher in the WRF group; however the duration of UF, liters of fluid removed and change in weight were not statistically different. Treatment with an aldosterone antagonist (18(45) vs. 14(24) p50.03) and lower baseline heart rate (72 618bpm vs. 78 61bpm p50.05) were associated with increased risk of WRF in univariate analysis. Echocardiography at admission showed higher E/E’ (19.29 6 6.53 vs. 16.25 6 6.71, p50.04), larger right ventricular diameter (RVD: 43.57 6 5.33 mm vs. 38.42 6 7.5 mm, p50.03) and higher pulmonary artery systolic pressure (64.81 6 17.32 mm Hg vs. 57.66 6 16.27 mm Hg, p50.05) by univariate analysis in the WRF group. After multivariate analysis, peak UF rate $ 150 mL/h (p50.04), lower heart rate at start of UF (p50.02) and higher PASP (p50.04) were independently associated with higher risk of WRF during UF. WRF was associated with increased length of hospitalization (13.9 6 14.1 vs. 8.9 6 5.8, p50.03), however mortality and repeat hospitalization rate did not differ between groups during at 15 months of follow-up. Conclusion: WRF occurred frequently in patients treated with UF. WRF was associated with increased length of hospitalization, however no difference in mortality or re-hospitalization rate was found. UF rate O 150 mL/h was associated with WRF. Increased LV filling pressures, lower heart rate and higher PASP on echocardiography at admission can identify patients at increased risk for developing WRF.
238 Improved Physical Function Confers Greater Quality of Life Benefits for NYHA Class III Than for NYHA Class II Patients Rebecca Gary1, Melinda Higgins1, Elaine Cress2, Andrew Smith3, Sandra Dunbar1; 1 Nursing, Emory University, Atlanta, GA; 2Kinesiology, University of Georgia, Athens, GA; 3Medicine, Emory University, Atlanta, GA Background: Heart failure results in a progressive decline in physical functioning and lowers quality of life (QOL) which has been shown to improve with exercise in some studies. Few studies have investigated whether improved functional performance also leads patients to report a better quality of life. We hypothesized that patients with HF who were more symptomatic and physically limited (NYHA class III) enrolled in a 12 week home based exercise program would have the most significant improvement in physical function and HRQOL than less compromised patients (NYHA class II) and controls. Methods: Patients were randomized to exercise (N540) or to a psycho-educational control group (N536). Continuous Scale Physical Function Performance test (CS-PFP10) that simulates daily household tasks (i.e., sweeping, laundry tasks, grocery carry), and QOL (Minnesota Living with Heart Failure Questionnaire [MLHFQ]) were evaluated at baseline (T1) and at 12-weeks (T2). Descriptive statistics, t-tests and linear regression models were used to analyze differences between groups. Results: Seventy-six NYHA II-III HF patients (mean age 63.9 6 12.4) participated; 51% were NYHA class III, 62% were Caucasian, and 59% were female. NYHA class III participants had significantly lower CS-PFP10 (31.7 6 14.9 vs. 45.8 6 15.9, p!0.001) and poorer QOL (43.4 6 24.9 vs 33.9 6 22.4, p50.085) than NYHA class II participants, respectively. After adjusting for baseline, T2 changes in CS-PFP10 scores (t 5 -3.9, p! 0.001) predicted better MLHFQ scores among NYHA class III participants (t 5 -3.7, p! 0.001) compared to NYHA class II participants (t5 -1.9, p!0.06). The association between change in CS-PFP10 and MLHFQ was stronger for NYHA class III (r50.36) than class II (r50.15) patients. In addition, the change in CS-PFP10 (5.1 vs 4.1 vs 1.2) and MLHFQ (-13.4 vs -6.6 vs -2.5) scores were greater among NYHA class III exercise participants than in NYHA class II exercise or control participants. Conclusions: Quality of life was improved subsequent to increased functional performance after 3 months of exercise in patients with Class II and III HF patients, with more impairment (Class III) reflecting greatest improvement. Functional performance tests that simulate daily household tasks may provide HF patients with a tangible measure of how exercise improves routine activities which in turn may translate into better QOL.
239 Renal Function in Patients With Acute Decompensated Heart Failure Treated With Ultrafiltration Nicholas Haglund1, Michael Johnston1, Ioana Dumitru1, Joan Mack2, Brian Lowes1, Eugenia Raichlin1; 1Cardiology, University of Nebraska Medical Center, Omaha, NE; 2Department of Nursing, University of Nebraska Medical Center, Omaha, NE
Fig. 1. In hospital death rates by heart failure, for all admissions for HF (top) and dichotomized by heart rhythm (sinus rhythm versus arterial fibrillation) (bottom). Loess plots with data density shown by vertical marks
Background: Ultrafiltration (UF) is used to treat patients with diuretic-resistant, acute decompensated heart failure (ADHF); however worsening renal function (WRF) is a common complication. The aim of the study was to identify clinical and echocardiographic predictors of WRF and effect on clinical outcomes in patients with ADHF treated with UF. Methods: From 1/2008 to 12/2011, 100 patients (age 64614 years, 61 % men) underwent UF at the University of Nebraska Medical Center. WRF was defined as a rise in serum creatinine level O 0.3 mg/ dl. Patients were divided into WRF and control groups based on changes in serum creatinine during UF. All patients were on optimal medical HF therapy. Average dose of intravenous furosemide before UF was 217 6 212 mg/day. Results: In the whole study population, creatinine increased from 1.960.7 mg/ dL to 2.0 6 1.1 mg/dL, (p,! 0.001) and WRF developed in 40 (40%) of patients. The peak UF rate (175672mL/h vs. 141 649mL/h, p5 0.01) was higher in the WRF group; however the duration of UF, liters of fluid removed and change in weight were not statistically different. Treatment with an aldosterone antagonist (18(45) vs. 14(24) p50.03) and lower baseline heart rate (72 618bpm vs. 78 61bpm p50.05) were associated with increased risk of WRF in univariate analysis. Echocardiography at admission showed higher E/E’ (19.29 6 6.53 vs. 16.25 6 6.71, p50.04), larger right ventricular diameter (RVD: 43.57 6 5.33 mm vs. 38.42 6 7.5 mm, p50.03) and higher pulmonary artery systolic pressure (64.81 6 17.32 mm Hg vs. 57.66 6 16.27 mm Hg, p50.05) by univariate analysis in the WRF group. After multivariate analysis, peak UF rate $ 150 mL/h (p50.04), lower heart rate at start of UF (p50.02) and higher PASP (p50.04) were independently associated with higher risk of WRF during UF. WRF was associated with increased length of hospitalization (13.9 6 14.1 vs. 8.9 6 5.8, p50.03), however mortality and repeat hospitalization rate did not differ between groups during at 15 months of follow-up. Conclusion: WRF occurred frequently in patients treated with UF. WRF was associated with increased length of hospitalization, however no difference in mortality or re-hospitalization rate was found. UF rate O 150 mL/h was associated with WRF. Increased LV filling pressures, lower heart rate and higher PASP on echocardiography at admission can identify patients at increased risk for developing WRF.