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.
Incidence and Predictors of Hyperkalemia in Patients With Heart Failure: An Analysis of the CHARM Program Akshay S. Desai, Karl Swedberg, John J. V. McMurray, Christopher B. Granger, Salim Yusuf, ...James B. Young, Mark E. Dunlap, Scott D. Solomon, James W. Hainer, Bertil Olofsson, Eric L. Michelson, Marc A. Pfeffer We examined the incidence and predictors of hyperkalemia in a broad population of patients with symptomatic heart failure enrolled in the CHARM (Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity) Program. Independent of assignment to candesartan or placebo, the risk of hyperkalemia increased with advanced age, male gender, baseline hyperkalemia, renal failure, diabetes, and background use of angiotensin-converting enzyme inhibitors or spironolactone. Candesartan increased the observed rate of hyperkalemia in these subgroups but was associated with a consistent reduction in the risk of cardiovascular death or heart failure hospitalization. Although renin-angiotensin-aldosterone antagonists improve clinical outcomes in heart failure patients, careful surveillance of serum potassium and creatinine is essential.
Influence of Beta-Blocker Continuation or Withdrawal on Outcomes in Patients Hospitalized With Heart Failure: Findings From the OPTIMIZE-HF Program Gregg C. Fonarow, William T. Abraham, Nancy M. ...Albert, Wendy Gattis Stough, Mihai Gheorghiade, Barry H. Greenberg, Christopher M. O'Connor, Jie Lena Sun, Clyde W. Yancy, James B. Young, on behalf of the OPTIMIZE-HF Investigators and Coordinators Whether beta-blocker therapy should be continued or withdrawn during hospitalization for heart failure has not been well studied. The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) data were analyzed according to whether beta-blocker therapy was continued, withdrawn, or not started. Among beta-blocker–eligible patients, there were 1,350 (57.1%) who were continued on beta-blocker therapy, 79 (3.3%) in whom therapy was withdrawn, and 303 (12.8%) who were eligible but not treated. Continuation of beta-blocker therapy was associated with a significantly lower adjusted risk of post-discharge death and death/rehospitalization compared with no beta-blocker therapy. In contrast, withdrawal of beta-blocker therapy was associated with higher adjusted post-discharge mortality risk compared with continuation.
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.
Quality of Care of and Outcomes for African Americans Hospitalized With Heart Failure: Findings From the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With ...Heart Failure) Registry Clyde W. Yancy, William T. Abraham, Nancy M. Albert, Robert Clare, Wendy Gattis Stough, Mihai Gheorghiade, Barry H. Greenberg, Christopher M. O'Connor, Lilin She, Jie Lena Sun, James B. Young, Gregg C. Fonarow The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) data were analyzed to compare quality of care, in-hospital and post-discharge mortality, and repeat hospital stay in African Americans with heart failure (HF) compared with non-African Americans. African Americans were more likely to receive evidence-based medications but less likely to receive discharge instructions and tobacco counseling. In multivariable analyses, African-American race was an independent predictor of lower in-hospital mortality (odds ratio 0.71; 95% confidence interval 0.57 to 0.87; p < 0.001) but similar hospital length of stay and post-discharge outcomes. After multivariable adjustment, African-American race was associated with higher angiotensin-converting enzyme inhibitor prescription and left ventricular function assessment; no other HF quality indicators were influenced by race.
Evaluation and Long-Term Prognosis of New-Onset, Transient, and Persistent Anemia in Ambulatory Patients With Chronic Heart Failure W. H. Wilson Tang, Wilson Tong, Anil Jain, Gary S. Francis, C. ...Martin Harris, James B. Young We reviewed records of 6,159 consecutive ambulatory patients with chronic heart failure followed up at a single center between 2001 and 2006, and found the prevalence of anemia (hemoglobin <12 g/dl for men, <11 g/dl for women) to be 17.2%. At 6-month follow-up, new-onset anemia developed in 16% of patients without prior anemia, whereas 43% patients with anemia at baseline had resolution of their hemoglobin levels. Higher total mortality rates were evident in patients with persistent anemia (58% vs. 31%, p < 0.0001) or with incident anemia (45% vs. 31%, p < 0.0001) compared with those with without anemia at 6 months.
Acute heart failure syndromes (AHFS) have emerged as a leading public health problem worldwide, accounting for a substantial number of hospitalizations and a high utilization of resources. Although ...in-hospital mortality rates are relatively low, patients with AHFS have very high early after-discharge mortality and rehospitalization rates. The majority of patients admitted with AHFS have coronary artery disease (CAD), which independently has an adverse impact on prognosis. The initial in-hospital and after-discharge management of AHFS may be dependent on clinical presentation: AHFS in patients with underlying CAD or acute coronary syndromes (ACS) complicated by heart failure. In addition, the extent and severity of CAD and the presence of ischemia and/or stunned/hibernating myocardium should be assessed for optimal management. Although the overall management of AHFS with CAD may be similar to that in patients with ACS complicated by heart failure, for which specific guidelines exist, management of the former is less well defined. Prospective studies of the assessment and treatment of CAD in patients with AHFS are urgently needed.
Predictors of In-Hospital Mortality in Patients Hospitalized for Heart Failure: Insights From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure ...(OPTIMIZE-HF) William T. Abraham, Gregg C. Fonarow, Nancy M. Albert, Wendy Gattis Stough, Mihai Gheorghiade, Barry H. Greenberg, Christopher M. O'Connor, Jie Lena Sun, Clyde W. Yancy, James B. Young, on behalf of the OPTIMIZE-HF Investigators and Coordinators Heart failure (HF) patients experience high rates of hospitalization and poor outcomes. This study using data from OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) aimed to develop a clinical model predictive of in-hospital mortality in a broad hospitalized HF patient population. Forty-five potential predictor variables were used in a stepwise logistic model for in-hospital mortality. Multivariable predictors of mortality included age, heart rate, systolic blood pressure, sodium, creatinine, and presence/absence of left ventricular systolic dysfunction. A scoring system was developed to predict mortality. Application of this risk-prediction algorithm might help identify patients at high risk for in-hospital mortality who might benefit from aggressive monitoring and intervention.
Characteristics, Treatments, and Outcomes of Patients With Preserved Systolic Function Hospitalized for Heart Failure: A Report From the OPTIMIZE-HF Registry Gregg C. Fonarow, Wendy Gattis Stough, ...William T. Abraham, Nancy M. Albert, Mihai Gheorghiade, Barry H. Greenberg, Christopher M. O’Connor, Jie Lena Sun, Clyde W. Yancy, James B. Young, for the OPTIMIZE-HF Investigators and Hospitals The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry was analyzed to compare 20,118 patients with left ventricular systolic dysfunction (LVSD) and 21,149 patients with preserved systolic function (PSF) (left ventricular ejection fraction ≥40%). Patients with PSF were more likely to be older, female, and Caucasian. Although length of hospital stay was the same in both groups, the risk of in-hospital mortality was lower in patients with PSF (2.9% vs. 3.9%; p < 0.0001). During 60- to 90 day post-discharge follow-up, patients with PSF had similar mortality risk (9.5% vs. 9.8%; p = 0.459) and rehospitalization rates compared with patients with LVSD.
Task Force 8: Training in Heart Failure Young, James B., MD, FACC; Abraham, William T., MD, FACC; Bourge, Robert C., MD, FACC ...
Journal of the American College of Cardiology,
2008, Volume:
51, Issue:
3
Journal Article
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