The importance of forward flow and venous congestion in diuretic response in acute heart failure: Insights from the ESCAPE trial
Por:
Eder, Maxwell, Griffin, Matthew, Moreno-Villagomez, Julieta, Bellumkonda, Lavanya, Maulion, Christopher, Asher, Jennifer, Wilson, Francis P., Cox, Zachary L., Ivey-Miranda, Juan B., Rao, Veena S., Butler, Javed, Borlaug, Barry A., McCallum, Wendy, Ramos-Mastache, Daniela, Testani, Jeffrey M.
Publicada:
15 jun 2023
Categoría:
Cardiology and cardiovascular medicine
Resumen:
Aims: Previous studies have suggested venous congestion as a stronger
mediator of negative cardio-renal in-teractions than low cardiac output,
with neither factor having a dominant role. While the influence of these
parameters on glomerular filtration have been described, the impact on
diuretic responsiveness is unclear. The goal of this analysis was to
understand the hemodynamic correlates of diuretic response in
hospitalized patients with heart failure.Methods and results: We
analyzed patients from the Evaluation Study of Congestive Heart Failure
and Pulmonary Artery Catheterization Effectiveness (ESCAPE) dataset.
Diuretic efficiency (DE) was defined as the average daily net fluid
output per doubling of the peak loop diuretic dose. We evaluated a
pulmonary artery catheter hemodynamic-guided cohort (n = 190) and a
transthoracic echocardiogram (TTE) cohort (n = 324) where DE was
evaluated with hemodynamic and TTE parameters. Metrics of ``forward
flow'' such as cardiac index, mean arterial pressure and left
ventricular ejection fraction were not associated with DE (p > 0.2 for
all). Worse baseline venous congestion was paradoxically associated with
better DE as assessed by right atrial pressure (RAP), right atrial area
(RAA), and right ventricular systolic and diastolic area (p < 0.05 for
all). Renal perfusion pressure (capturing both congestion and forward
flow) was not associated with diuretic response (p = 0.84).Conclusions:
Worse venous congestion was weakly associated with better loop diuretic
response. Metrics of ``forward flow'' did not demonstrate any
correlation with diuretic response. These observations raise questions
about the concept of central hemodynamic perturbations as the primary
drivers of diuretic resistance on a population level in HF.
Filiaciones:
Eder, Maxwell:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Griffin, Matthew:
Department of Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
Stanford Univ, Dept Crit Care Med, Sch Med, Palo Alto, CA USA
Moreno-Villagomez, Julieta:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Universidad Nacional Autónoma de México, Mexico City, Mexico
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Univ Nacl Autonoma Mexico, Mexico City, Mexico
Bellumkonda, Lavanya:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Maulion, Christopher:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Asher, Jennifer:
Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Comparat Med, Sch Med, New Haven, CT USA
Wilson, Francis P.:
Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Clin & Translat Res Accelerator, Sch Med, New Haven, CT USA
Cox, Zachary L.:
Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, United States
Lipscomb Univ, Dept Pharm Practice, Coll Pharm, Nashville, TN USA
Ivey-Miranda, Juan B.:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Inst Mexicano Seguro Social, Hosp Cardiol, Mexico City, Mexico
Rao, Veena S.:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Butler, Javed:
Department of Medicine, University of Mississippi Medical CenterMS, United States
Univ Mississippi, Dept Med, Med Ctr, Jackson, MS 39216 USA
Borlaug, Barry A.:
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
Mayo Clin, Dept Cardiovasc Med, Rochester, MN USA
McCallum, Wendy:
Division of Nephrology, Tufts medical Center, Boston, MA, United States
Tufts Med Ctr, Div Nephrol, Boston, MA USA
Ramos-Mastache, Daniela:
Universidad Nacional Autónoma de México, Mexico City, Mexico
Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Mexico City, Mexico
Univ Nacl Autonoma Mexico, Fac Estudios Super Iztacala, Mexico City, Mexico
Testani, Jeffrey M.:
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
Yale Univ, Dept Internal Med, Sect Cardiovasc Med, Sch Med, New Haven, CT USA
Yale Univ, Sect Cardiovasc Med, Sch Med, 135 Coll St,Suite 230, New Haven, CT 06510 USA
|