A Novel Index for Survival in Acute Heart Failure: Diuretic Efficiency Score

Öz

Aims: Acute heart failure (AHF) is the leading cause of hospital admissions among adults ≥65. Loop diuretics are the mainstay of treatment of congestion in AHF. Response to loop diuretics is closely related to morbidity and mortality. In this study, we aimed to investigate (1) the clinical determinants of diuretic efficiency (DE) by using three separate indicators for assessing DE and (2) the prognostic effect of diuretic efficiency in acutely decompensated heart failure patients. Methods: 42 consecutive patients admitted to the hospital for acutely decompensated heart failure were included. Early diuretic response, spot urine sodium excretion (UNa), and hemoconcentration were evaluated individually to predict loop diuretic efficiency. Results: Good early diuretic response (EDR) was associated with higher diastolic blood pressure on admission and eGFR, atrial fibrillation, and bolus dosing of intravenous furosemide. Hypertension and low systolic blood pressure on admission were inversely related to hemoconcentration. Conclusion: Diuretic efficiency is strongly influenced by the heart rhythm, renal function, blood pressure, prevalence of hypertension, and schedule of furosemide administration. We developed a novel, 3-variable index called DES (diuretic efficiency score) that predicts mortality in AHF patients. Future research in larger cohorts is needed to validate DES as a predictor of mortality in heart failure.

Anahtar Kelimeler

• diuretics
• heart failure
• survival

Akut Kalp Yetmezliğinde Sağkalım Değerlendirmek için Yeni Bir Skor: Diüretik Etkinlik Skoru

Öz

Amaç: Akut kalp yetmezliği (AKY) 65 yaş üstü yetişkinlerde hastaneye yatışların en sık nedenidir. Kıvrım diüretikleri, AKY'de konjesyon tedavisinin temel unsurudur. Kıvrım diüretiklerine olan yanıt morbidite ve mortalite ile yakından ilişkilidir. Bu çalışmada; (1) üç ayrı gösterge kullanarak diüretik etkinliğinin (DE) klinik belirleyicilerini ve (2) akut dekompanse kalp yetmezliği hastalarında diüretik etkinliğinin prognostik etkisini araştırmayı amaçladık. Gereç ve Yöntem: Akut dekompanse kalp yetersizliği nedeniyle hastaneye yatırılan 42 hasta çalışmaya dahil edildi. Kıvrım diüretik etkinliğini belirlemek için erken diüretik yanıtı, spot idrar sodyum atılımı (UNa) ve hemokonsantrasyon parametreleri ayrı ayrı değerlendirildi. Bulgular: İyi erken diüretik yanıtı (EDY), başvuru sırasındaki yüksek diyastolik kan basıncı ve eGFR, atriyal fibrilasyon ve intravenöz furosemidin bolus doz şeklind verilmesi ile ilişkili olarak tespit edildi. Hipertansiyon ve başvuru sırasındaki düşük sistolik kan basıncı hemokonsantrasyon ile ters ilişkili olarak bulundu. Sonuç: Diüretik etkinliği kalp ritmi, böbrek fonksiyonu, kan basıncı, hipertansiyon varlığı ve furosemid uygulama şeklinden güçlü bir şekilde etkilenmektedir. Mevcut çalışmada, AKY hastalarında mortaliteyi öngördürmede kullanılabilecek ve DES (diüretik etkinlik skoru) adı verilen yeni, 3 değişkenli bir indeks geliştirildi.

Anahtar Kelimeler

• diüretik
• kalp yetmezliği
• sağkalım

Kaynakça

1. 1. Abdo AS. Hospital Management of Acute Decompensated Heart Failure. Am J Med Sci. 2017;353(3):265-274.
2. 2. Farmakis D, Parissis J, Lekakis J, Filippatos G. Acute heart failure: Epidemiology, risk factors, and prevention. Rev Esp Cardiol (Engl Ed). 2015;68(3):245-8.
3. 3. Raj L, Maidman SD, Adhyaru BB. Inpatient management of acute decompensated heart failure. Postgrad Med J. 2020;96(1131):33-42.
4. 4. Ter Maaten JM, Valente MA, Damman K, Hillege HL, Navis G, A Voors A. Diuretic response in acute heart failure-pathophysiology, ealuation, and therapy. Nat Rev Cardiol. 2015;12(3):184- 92.
5. 5. Ter Maaten JM, Valente MA, Damman K, Cleland JG, Givertz MM, Metra M, O’Connor CM, Teerlink JR, Ponikowski P, Bloomfield DM, Cotter G, Davison B, Subacius H, J van Veldhuisen D, Van der Meer P, Hillege HL, Gheorghiade M, Voors AA. Combining Diuretic Response and Hemoconcentration to Predict Rehospitalization After Admission for Acute Heart Failure. Circ Heart Fail. 2016;9(6):e002845.
6. 6. Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, testani JM, Wilson Tang WH, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(2):137-155.
7. 7. Voors AA, Davison BA, Teerlink JR, Felker GM, Cotter G, Filippatos G, Greenberg BH, Pang PS, Levin B, Hua TA, Severin T, Ponikowski P, Metra M. Diuretic response in patients with acute decompensated heart failure: characteristics and clinical outcome--an analysis from RELAX-AHF. Eur J Heart Fail. 2014;16(11):1230-40.
8. 8. Neuberg GW, Miller AB, O’Connor CM, Belkin RN, Carson PE, Cropp AB, Frid DJ, Nye RG, Pressler ML, Wertheimer JH, Packer M. Prospective Randomized Amlodipine Survival Evaluation. Diuretic resistance predicts mortality in patients with advanced heart failure. Am Heart J. 2002;144(1):31-8.

9. 9. Kuroda S, Damman K, Ter Maaten JM, Voors AA, Okumura T, Kida K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Kitai T, Yoshida K, Matsumura A, Matsue Y. Very Early Diuretic Response After Admission for Acute Heart Failure. J Card Fail. 2019 Jan;25(1):12-19. doi: 10.1016/j.cardfail.2018.09.004. Epub 2018 Sep 13. PMID: 30219549.
10. 10. Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biom J. 2005;47(4):458-472.
11. 11. Rossignol P, Coats AJ, Chioncel O, Spoletini I, Rosano G. Renal function, electrolytes, and congestion monitoring in heart failure. Eur Heart J Suppl. 2019;21(Suppl M):M25-M31.
12. 12. Smeets CJP, Lee S, Groenendaal W, Squillace G, Vranken J, Canniere HD, Van Hoof C, Grieten L, Mullens W, Nijst P, Vandervoort PM. The Added Value of In-Hospital Tracking of the Efficacy of Decongestion Therapy and Prognostic Value of a Wearable Thoracic Impedance Sensor in Acutely Decompensated Heart Failure With Volume Overload: Prospective Cohort Study. JMIR Cardio. 2020;4(1):e12141.
13. 13. Valente MA, Voors AA, Damman K, Van Veldhuisen DJ, Massie BM, O’Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, Davison B, Cleland JGF, Givertz MM, Bloomfield DM, Fiuzat M, Dittrich HC, Hillege HL. Diuretic response in acute heart failure: clinical characteristics and prognostic significance. Eur Heart J. 2014;35(19):1284-93.
14. 14. Rahman R, Paz P, Elmassry M, Mantilla B, Dobbe L, Shurmur S, Nugent K. Diuretic Resistance in Heart Failure. Cardiol Rev. 2021;29(2):73-81.
15. 15. Ter Maaten JM, Valente MA, Metra M, Bruno N, O’Connor CM, Ponikowski P, Teerlink JR, Cotter , Davison B, Cleland JG, Givertz MM, Bloomfield DM, Dittrich HC, Van Veldhuisen DJ, Hillege HL, Damman K, Voors AA. A combined clinical and biomarker approach to predict diuretic response in acute heart failure. Clin Res Cardiol. 2016;105(2):145-53.
16. 16. Rossi A, Enriquez-Sarano M, Burnett JC Jr, Lerman A, Abel MD, Seward JB. Natriuretic peptide levels in atrial fibrillation: a prospective hormonal and Doppler-echocardiographic study. J Am Coll Cardiol. 2000;35(5):1256-62.
17. 17. Roy D, Paillard F, Cassidy D, Bourassa MG, Gutkowska J, Genest J, Cantin M. Atrial natriuretic factor during atrial fibrillation and supraventricular tachycardia. J Am Coll Cardiol. 1987;9(3):509-14.
18. 18. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O’Connor CM. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797-805.
19. 19. Chan JSK, Kot TKM, Ng M, Harky A. Continuous Infusion Versus Intermittent Boluses of Furosemide in Acute Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail. 2020;26(9):786-793.
20. 20. Honda S, Nagai T, Nishimura K, Nakai M, Honda Y, Nakano H, Iwakami N, Sugano Y, Asaumi Y, Aiba T, Noguchi T, Kusano K, Yokoyama H, Ogawa H, Yasuda S, Anzai T; NaDEF investigators. Long-term prognostic significance of urinary sodium concentration in patients with acute heart failure. Int J Cardiol. 2018;254:189-194.
21. 21. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW; ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294(13):1625-33.
22. 22. Yan Q, Chen S. Hemoconcentration is a valuable predictor of prognosis in patients with acute heart failure. Exp Ther Med. 2020;19(4):2792-2798.
23. 23. Oh J, Kang SM, Hong N, Youn JC, Han S, Jeon ES, Cho MC, Kim JJ, Yoo BS, Chae SC, Oh BH, Choi DJ, Lee MM, Ryu KH. Hemoconcentration is a good prognostic predictor for clinical outcomes in acute heart failure: data from the Korean Heart Failure (KorHF) Registry. Int J Cardiol. 2013;168(5):4739-43.