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Circulation. Heart Failure Nov 2014Outcomes associated with episodes of hypotension while hospitalized with acute decompensated heart failure are not well understood. (Observational Study)
Observational Study Randomized Controlled Trial
BACKGROUND
Outcomes associated with episodes of hypotension while hospitalized with acute decompensated heart failure are not well understood.
METHODS AND RESULTS
Using data from Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), we assessed factors associated with in-hospital hypotension and subsequent 30-day outcomes. Patients were classified as having symptomatic or asymptomatic hypotension. Multivariable logistic regression was used to determine factors associated with in-hospital hypotension, and Cox proportional hazards models were used to assess the association between hypotension and 30-day outcomes. We also tested for treatment interaction with nesiritide on 30-day outcomes and the association between in-hospital hypotension and renal function at hospital discharge. Overall, 1555 of 7141 (21.8%) patients had an episode of hypotension, of which 73.1% were asymptomatic and 26.9% were symptomatic. Factors strongly associated with in-hospital hypotension included randomization to nesiritide (odds ratio, 1.98; 95% confidence interval [CI], 1.76-2.23; P<0.001), chronic metolazone therapy (odds ratio, 1.74; 95% CI, 1.17-2.60; P<0.001), and baseline orthopnea (odds ratio, 1.31; 95% CI, 1.13-1.52; P=0.001) or S3 gallop (odds ratio, 1.21; 95% CI, 1.06-1.40; P=0.006). In-hospital hypotension was associated with increased hazard of 30-day mortality (hazard ratio, 2.03; 95% CI, 1.57-2.61; P<0.001), 30-day heart failure hospitalization or mortality (hazard ratio, 1.58; 95% CI, 1.34-1.86; P<0.001), and 30-day all-cause hospitalization or mortality (hazard ratio, 1.40; 95% CI, 1.22-1.61; P<0.001). Nesiritide had no interaction on the relationship between hypotension and 30-day outcomes (interaction P=0.874 for death, P=0.908 for death/heart failure hospitalization, P=0.238 death/all-cause hospitalization).
CONCLUSIONS
Hypotension while hospitalized for acute decompensated heart failure is an independent risk factor for adverse 30-day outcomes, and its occurrence highlights the need for modified treatment strategies.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique identifier: NCT00475852.
Topics: Aged; Female; Heart Failure; Hospital Mortality; Hospitalization; Humans; Hypotension; Logistic Models; Male; Middle Aged; Natriuretic Agents; Natriuretic Peptide, Brain; Outcome Assessment, Health Care; Prognosis; Proportional Hazards Models
PubMed: 25281655
DOI: 10.1161/CIRCHEARTFAILURE.113.000872 -
Hospital Pharmacy Dec 2019Thiazide diuretics are often utilized to overcome loop diuretic resistance when treating acute decompensated heart failure (ADHF). In addition to a large cost...
Thiazide diuretics are often utilized to overcome loop diuretic resistance when treating acute decompensated heart failure (ADHF). In addition to a large cost advantage, several pharmacokinetic advantages exist when administering oral metolazone (MTZ) compared with intravenous (IV) chlorothiazide (CTZ), yet many providers are reluctant to utilize an oral formulation to treat ADHF. The purpose of this study was to compare the increase in 24-hour total urine output (UOP) after adding MTZ or CTZ to IV loop diuretics (LD) in patients with heart failure with reduced ejection fraction (HFrEF). From September 2013 to August 2016, 1002 patients admitted for ADHF received either MTZ or CTZ in addition to LD. Patients were excluded for heart failure with preserved ejection fraction (HFpEF) (n = 469), <24-hour LD or UOP data prior to drug initiation (n = 129), or low dose MTZ/CTZ (n = 91). A total of 168 patients were included with 64% receiving CTZ. No significant difference was observed between the increase in 24-hour total UOP after MTZ or CTZ initiation (1458 [514, 2401] mL vs 1820 [890, 2750] mL, = .251). Both MTZ and CTZ similarly increased UOP when utilized as an adjunct to IV LD. These results suggest that while thiazide agents can substantially increase UOP in ADHF patients with HFrEF, MTZ and CTZ have comparable effects.
PubMed: 31762481
DOI: 10.1177/0018578718795855 -
Journal of Palliative Medicine Oct 2017Palliative care for advanced heart failure (HF) is generally recommended. However, few reports have focused on the particulars of treatment, or the clinical course of HF...
BACKGROUND
Palliative care for advanced heart failure (HF) is generally recommended. However, few reports have focused on the particulars of treatment, or the clinical course of HF on a specific treatment regimen.
OBJECTIVE
Palliation adequate to allow patients to avoid HF admission and die at home.
METHODS
Patients from a veterans administration regional practice with multiple, recent hospital admissions were enrolled in community hospice programs. Treatment of HF with reduced left ventricular ejection fraction (HFrEF) included guidelines-directed medical therapy, digoxin, opioids, and oral bumetanide (with metolazone as needed) rather than intravenous diuretics. Levodopa (l-dopa) was added when conventional therapy failed to control symptoms. HF with preserved EF was also treated with bumetanide and opioids.
RESULTS
Thirty male veterans, 23 of them with HFrEF, had 90 HF admissions in the 6 months before enrollment, and 3 HF admissions during follow-up of at least 14 months. Twenty-one patients died, 18 of them at home; 14 died within 5 months, and the rest lived much longer. Failure to improve with initial therapy predicted early death. Results were similar for those with reduced and preserved left ventricular ejection fraction. L-dopa was started in 13 patients and tolerated by 8 patients; functional class improved and B-type natriuretic peptide declined after treatment.
CONCLUSIONS
With this treatment protocol, there were few HF admissions and patients were able to die at home. It can be used as a guide to therapy, or as an approach that can be tested with additional study.
Topics: Aged; Aged, 80 and over; Clinical Protocols; Heart Failure; Hospice Care; Humans; Male; Middle Aged; Palliative Care; Patient Selection; United States; United States Department of Veterans Affairs; Veterans
PubMed: 28530501
DOI: 10.1089/jpm.2017.0035