Objectives To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced ...decompensated heart failure (ADHF). Background Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF. Methods A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine ≥0.3 mg/dl during hospitalization. Results In the study cohort (age 57 ± 14 years, cardiac index 1.9 ± 0.6 l/min/m2 , left ventricular ejection fraction 20 ± 8%, serum creatinine 1.7 ± 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 ± 7 mm Hg vs. 12 ± 6 mm Hg, p < 0.001) and after intensive medical therapy (11 ± 8 mm Hg vs. 8 ± 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates. Conclusions Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.
Sodium Nitroprusside for Advanced Low-Output Heart Failure Mullens, Wilfried, MD; Abrahams, Zuheir, MD, PhD; Francis, Gary S., MD, FACC ...
Journal of the American College of Cardiology,
07/2008, Volume:
52, Issue:
3
Journal Article
Peer reviewed
Open access
Sodium Nitroprusside for Advanced Low-Output Heart Failure Wilfried Mullens, Zuheir Abrahams, Gary S. Francis, Hadi N. Skouri, Randall C. Starling, James B. Young, David O. Taylor, W. H. Wilson Tang ...Inotropic drugs are often preferred over vasodilators in patients with end-stage, low-output heart failure. We reviewed consecutive patients admitted between 2000 and 2005 with acute decompensated heart failure with a cardiac index ≤2 l/min/m2 . Compared with control patients, treatment with sodium nitroprusside was associated with greater improvement in hemodynamics, higher rates of transitioning oral vasodilators at discharge, and lower rates of all-cause mortality and all-cause mortality/cardiac transplant without increase in rehospitalization, inotropic use, or worsening renal function.
Elevated Intra-Abdominal Pressure in Acute Decompensated Heart Failure: A Potential Contributor to Worsening Renal Function? Wilfried Mullens, Zuheir Abrahams, Hadi N. Skouri, Gary S. Francis, David ...O. Taylor, Randall C. Starling, Emil Paganini, W. H. Wilson Tang We measured intra-abdominal pressure (IAP) using a simple transvesical technique in 40 consecutive patients admitted for acute decompensated heart failure without overt abdominal symptoms. Among them, 60% had elevated IAP (≥8 mm Hg). Elevated IAP was directly associated with worse renal function, and intensive medical therapy resulted in improvement in both hemodynamic measures and IAP. However, reduction in IAP is better correlated with improvement in renal function than any hemodynamic variable, suggesting a potential contribution of elevated IAP in the pathophysiology of the cardiorenal syndrome.
Abstract Objective The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery ...disease (CAD) burden. Methods We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query. Results A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD ( P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median interquartile range25–75 : $2952 $307–2952 and $235 $0–2880) when compared with patients with obstructive CAD (median interquartile range25–75 : $5832 $5498–17,459; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred. Conclusion Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.
PDF
