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
ISSN: 01675273





INTERNATIONAL JOURNAL OF CARDIOLOGY
Editorial
ELSEVIER IRELAND LTD, ELSEVIER HOUSE, BROOKVALE PLAZA, EAST PARK SHANNON, CO, CLARE, 00000, IRELAND, Irlanda
Tipo de documento: Article
Volumen: 381 Número:
Páginas: 57-61
WOS Id: 000991818400001
ID de PubMed: 37023862

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