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Subjective Versus Objective Classification of NYHA Class IV
Journal of Cardiac Failure Vol. 16 No. 8 2010
Letters to the Editor Subjective Versus Objective Classification of NYHA Class IV
the UNLOAD trial there were no differences in the baseline characteristics of the patients randomized to either ultrafiltration of intravenous diuretics.1 The differences in the baselines characteristics observed in the present analysis may simply reflect the further subdivision of the intravenous diuretics group according to therapy with bolus versus continuous infusion diuretic therapy.2 With this limitation in mind, we wish to point out that whereas the intravenous continuous diuretic infusion group had greater functional limitations according to the subjective criteria of NYHA class and MLWHF score, it did not have greater severity of illness according to the objective criteria of arterial blood pressure and B-type natriuretic peptide levels.2 In our opinion these findings simply support our conclusion that the observed differences in the outcomes cannot be attributed to substantial differences in the baseline characteristics of the study groups.
To the Editor: I read with interest the analysis by Costanzo et al1 on the relevance of the removal of isotonic rather than hypotonic fluid in patients with decompensated heart failure. Although not directly related to the study findings, examining of the baseline characteristics table reveals some contradictory findings. The prevalence of New York Heart Association Class IVin the continuous diuretics group was twice as frequent when compared with the bolus diuretics group and these patients had higher Minnesota Living with Heart Failure scores. Yet, they had higher systolic blood pressure 134 6 23 (mm Hg) versus 126 6 24 (mm Hg), lower heart rate 80 6 15 (beats/min) versus 84 6 17 (beats/min) and lower serum brain natriuretic peptide 869 6 895 (pg/mL) versus 1494 6 1655 (pg/mL). I would appreciate the authors’ comments.
Maria Rosa Costanzo, MD, FACC, FAHA On behalf of the UNLOAD Investigators Midwest Heart Specialists Heart Failure and Pulmonary Hypertension Programs Naperville, IL
Jalal K. Ghali, MD Cardiology DMC Cardiovascular Institute Detroit, MI Disclosures None.
Disclosures Reference
Dr. Costanzo receives speaking and consulting honoraria from CHF Solutions.
1. Costanzo MR, Saltzbert MT, Jessup M, Teerlink JR, Sobotka PA. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure (UNLOAD) investigators. Ultrafiltration is associated with fewer rehospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Cardiac Fail 2010;16:277e84.
References
doi:10.1016/j.cardfail.2010.06.002 1. Costanzo MR, Guglin M, Saltzberg M, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007;49:675e83. 2. Costanzo MR, Saltzberg MT, Jessup M, Teerlink JR, Sobotka PA. Ultrafiltration Is associated with fewer re-hospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Cardiac Fail 2010;16:277e84.
Reply
To the Editor: We appreciate the opportunity to respond to Dr. Ghali’s insightful comments. First it is important to note that in
doi:10.1016/j.cardfail.2010.06.001
707
Letters to the Editor Subjective Versus Objective Classification of NYHA Class IV
the UNLOAD trial there were no differences in the baseline characteristics of the patients randomized to either ultrafiltration of intravenous diuretics.1 The differences in the baselines characteristics observed in the present analysis may simply reflect the further subdivision of the intravenous diuretics group according to therapy with bolus versus continuous infusion diuretic therapy.2 With this limitation in mind, we wish to point out that whereas the intravenous continuous diuretic infusion group had greater functional limitations according to the subjective criteria of NYHA class and MLWHF score, it did not have greater severity of illness according to the objective criteria of arterial blood pressure and B-type natriuretic peptide levels.2 In our opinion these findings simply support our conclusion that the observed differences in the outcomes cannot be attributed to substantial differences in the baseline characteristics of the study groups.
To the Editor: I read with interest the analysis by Costanzo et al1 on the relevance of the removal of isotonic rather than hypotonic fluid in patients with decompensated heart failure. Although not directly related to the study findings, examining of the baseline characteristics table reveals some contradictory findings. The prevalence of New York Heart Association Class IVin the continuous diuretics group was twice as frequent when compared with the bolus diuretics group and these patients had higher Minnesota Living with Heart Failure scores. Yet, they had higher systolic blood pressure 134 6 23 (mm Hg) versus 126 6 24 (mm Hg), lower heart rate 80 6 15 (beats/min) versus 84 6 17 (beats/min) and lower serum brain natriuretic peptide 869 6 895 (pg/mL) versus 1494 6 1655 (pg/mL). I would appreciate the authors’ comments.
Maria Rosa Costanzo, MD, FACC, FAHA On behalf of the UNLOAD Investigators Midwest Heart Specialists Heart Failure and Pulmonary Hypertension Programs Naperville, IL
Jalal K. Ghali, MD Cardiology DMC Cardiovascular Institute Detroit, MI Disclosures None.
Disclosures Reference
Dr. Costanzo receives speaking and consulting honoraria from CHF Solutions.
1. Costanzo MR, Saltzbert MT, Jessup M, Teerlink JR, Sobotka PA. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure (UNLOAD) investigators. Ultrafiltration is associated with fewer rehospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Cardiac Fail 2010;16:277e84.
References
doi:10.1016/j.cardfail.2010.06.002 1. Costanzo MR, Guglin M, Saltzberg M, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007;49:675e83. 2. Costanzo MR, Saltzberg MT, Jessup M, Teerlink JR, Sobotka PA. Ultrafiltration Is associated with fewer re-hospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Cardiac Fail 2010;16:277e84.
Reply
To the Editor: We appreciate the opportunity to respond to Dr. Ghali’s insightful comments. First it is important to note that in
doi:10.1016/j.cardfail.2010.06.001
707