Hemodynamic Congestion at Hospital Discharge Predicts Rehospitalization during Short Term Follow Up in Acute Heart Failure Patients
Background: Hemodynamic congestion is an increase in left ventricular diastolic pressure (LVEDP) without clinical symptoms and signs of congestion. Current acute heart failure (AHF) treatment goals only focused on improving clinical congestion. The purpose of this study was to investigate whether hemodynamic congestion measured by NT-proBNP level and ePCWP at hospital discharge could predict short term clinical outcomes in AHF patients.
Method: This prospective cohort study was conducted at dr. Saiful Anwar General Hospital Malang from January to July 2018. All patients got AHF treatment according to the 2016 ESC guidelines for heart failure. All patients were discharged without symptoms and signs of clinical congestion. Hemodynamic congestion at hospital discharge was defined as failure of treatment during hospitalization to achieve a reduction in NT-proBNP level >30% and/or ePCWP at hospital discharge >16 mmHg. NT-proBNP level and ePCWP were measured at 0-12 hours after hospital admisssion and at hospital discharge. ePCWP was measured using echocardiography. The clinical outcomes assessed were AHF rehospitalization and cardiovascular mortality within 30 days after hospitral discharge. Subgroup analysis was performed to determine therapeutic regimens that are effective in improving hemodynamic congestion.
Result: A total of 33 AHF patients were included in this study. 48% patients were discharged with hemodynamic congestion and 52% patients discharged without hemodynamic congestion. Patients with hemodynamic congestion at hospital discharge showed a higher rehospitalization within 30 days (8 [50%] vs 1 [5.9%]; P = 0.007). Mortality within 30 days in both groups did not show a significant difference (2 [12.5%] vs 0 [0%]; P = 0.277). Treatment regiment of optimal dose of ACEi/ARB, Î²-blockers, and diuretics was associated with improvement of hemodynamic congestion (P = 0.026; r = 0.454), a decrease in NT-proBNP> 66% (P = 0.02; r = 0,574), and achievement of ePCWP <16 (P = 0,013; r = 0,493) at hospital discharge in HFrEF patients.
Conclusion: This study showed that hemodynamic congestion assessed with NT-proBNP level and ePCWP at hospital discharge increased 30 day rehospitalization in AHF patients. In HFrEF, improvements in hemodynamic congestion can be achieved by giving the treatment regiment of optimal dose of ACEi/ARB, Î²-blockers, and diuretics.
Keyword: Acute heart failure, hemodynamic congestion, NT-proBNP, ePCWP
Force TL, Hu S, Jaarsma T, Krum H, Rastogi V,
Rohde LE. Heart failure: preventing disease and
death worldwide. ESC Heart Failure 2014; 1(1):4-
2. Ziaeian B, Fonarow GC. Epidemiology and aetiology
of heart failure. Nature Reviews Cardiology 2016;
3. Badan Penelitian dan Pengembangan Kesehatan
Kementerian Kesehatan Republik Indonesia. Laporan
Riskesdas 2013. Hal: 90-91.
4. Cook C, Cole G, Asaria P, Jabbour R, Francis DP.
The annual global economic burden of heart failure.
International Journal of Cardiology 2014;
5. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland
JGF, Coats AJS, Falk V, Gonzalez-Juanatey JR,
Harjola V-P, Jankowska EA. 2016 ESC Guidelines
for the diagnosis and treatment of acute and chronic
heart failure: The Task Force for the diagnosis and
treatment of acute and chronic heart failure of the
European Society of Cardiology (ESC) Developed
with the special contribution of the Heart Failure
Association (HFA) of the ESC. European heart journal
6. Farmakis D, Parissis J, Lekakis J, Filippatos G.
Acute heart failure: epidemiology, risk factors, and
prevention. Revista Espanola de Cardiologia 2015;
7. Felker GM, Teerlink JR. Diagnosis and Management
of Acute Heart Failure. In: Mann DL, Zipes
DP, Libby P, Bonow RO, eds. Braunwald's Heart
Disease: A Textbook of Cardiovascular Medicine.
10 ed. Philadelphia, USA: Elsevier Saunders; 2014.
8. Gheorghiade M, Filippatos G, De Luca L, Burnett
J. Congestion in acute heart failure syndromes: an
essential target of evaluation and treatment. The
American journal of medicine 2006; 119(12):S3-
8. Stevenson LW, Zile M, Bennett TD, Kueffer FJ,
Jessup ML, Adamson P, Abraham WT, Manda V,
Bourge RC. Chronic ambulatory intracardiac pressures
and future heart failure events. Circulation
Heart failure 2010; 3(5):580-587.
10. Inomata T. Biomarkers: New Horizon for Heart 2
Failure Practice. In: Sato N, ed. Therapeutic Strategies
for Heart Failure. Tokyo: Springer Japan; 2018.
11. Vest AR, Jr. FH. Preload. In: Anwaruddin S, Martin
JM, Stephens JC, Askari AT, eds. Cardiovascular
Hemodynamics An Introductory Guide. Philadelphia,
USA: Humana Press; 2013. p. 3-27.
12. Bayes-Genis A, Lopez L, Zapico E, Cotes C, Santalo
M, Ordonez-Llanos J, Cinca J. NT-ProBNP Reduction
Percentage During Admission for Acutely
Decompensated Heart Failure Predicts Long-Term
Cardiovascular Mortality. Journal of cardiac failure
13. Salah K, Kok WE, Eurlings LW, Bettencourt P, Pimenta
JM, Metra M, Bayes-Genis A, Verdiani V,
Bettari L, Lazzarini V. A novel discharge risk model
for patients hospitalised for acute decompensated
heart failure incorporating N-terminal pro-B-type
natriuretic peptide levels: a European coLlaboration
on Acute decompeNsated Heart Failure: ELANHF
Score. Heart (British Cardiac Society) 2014;
14. Fonarow GC, Stevenson LW, Steimle AE, Hamilton
MA, Moriguchi JD, Walden JA, et al. Persistently
high left-ventricular filling pressures predict mortality
despite angiotensin-converting enzyme-inhibition
in advanced heart failure. Circulation.
15. Fonarow GC. The treatment targets in acute decompensated
heart failure. Reviews in cardiovascular
medicine 2001; 2:S7-S12.
16. J Romero-Bermejo F, Ruiz-Bailen M, Guerrero-
De-Mier M, Lopez-Alvaro J. Echocardiographic
hemodynamic monitoring in the critically ill patient.
Current cardiology reviews 2011; 7(3):146-
17. Pozzoli M, Traversi E, Roelandt J. Non-invasive estimation
of left ventricular filling pressures by Doppler
echocardiography. European Journal of Echocardiography
18. Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi
WA, Quinones MA. Doppler tissue imaging: a
noninvasive technique for evaluation of left ventricular
relaxation and estimation of filling pressures.
Journal of the American College of Cardiology 1997;
19. Nagueh SF, Mikati I, Kopelen HA, Middleton KJ,
Quinones MA, Zoghbi WA. Doppler estimation of
left ventricular filling pressure in sinus tachycardia.
Circulation 1998; 98(16):1644-1650.
20. Gheorghiade M, Follath F, Ponikowski P, Barsuk
JH, Blair JEA, Cleland JG, Dickstein K, Drazner
MH, Fonarow GC, Jaarsma T. Assessing and grading
congestion in acute heart failure: a scientific
statement from the acute heart failure committee of
the heart failure association of the European Society
of Cardiology and endorsed by the European Society
of Intensive Care Medicine. European journal of
heart failure 2010; 12(5):423-433.
21. Stienen S, Salah K, Moons AH, Bakx AL, van Pol
P, Kortz RAM, Ferreira JoP, Marques I, Schroeder-
Tanka JM, Keijer JT. NT-proBNP (N-Terminal
pro-B-Type Natriuretic Peptide)-Guided Therapy
in Acute Decompensated Heart Failure: PRIMA
II Randomized Controlled Trial (Can NT-ProBNP-
Guided Therapy During Hospital Admission
for Acute Decompensated Heart Failure Reduce
Mortality and Readmissions?). Circulation 2018;
22. Senni M, Paulus WJ, Gavazzi A, Fraser AG, Diez
J, Solomon SD, Smiseth OA, Guazzi M, Lam CSP,
Maggioni AP. New strategies for heart failure with
preserved ejection fraction: the importance of targeted
therapies for heart failure phenotypes. European
heart journal 2014; 35(40):2797-2815.
23. Ferrari R, Bohm M, Cleland JGF, Paulus WJS,
Pieske B, Rapezzi C, Tavazzi L. Heart failure with
preserved ejection fraction: uncertainties and dilemmas.
European journal of heart failure 2015;
24. Maggioni AP, Anker SD, Dahlstrom U, Filippatos
G, Ponikowski P, Zannad F, Amir O, Chioncel O,
Leiro MC, Drozdz J. Are hospitalized or ambulatory
patients with heart failure treated in accordance
with European Society of Cardiology guidelines?
Evidence from 12 440 patients of the ESC Heart
Failure Long-Term Registry. European journal of
heart failure 2013; 15(10):1173-1184.
25. Pitt B, Pfeffer MA, Assmann SF, Boineau R, Anand
IS, Claggett B, Clausell N, Desai AS, Diaz R, Fleg
JL. Spironolactone for heart failure with preserved
ejection fraction. New England Journal of Medicine
26. Solomon SD, Zile M, Pieske B, Voors A, Shah A,
Kraigher-Krainer E, Shi V, Bransford T, Takeuchi
M, Gong J. The angiotensin receptor neprilysin inhibitor
LCZ696 in heart failure with preserved ejection
fraction: a phase 2 double-blind randomised
controlled trial. The Lancet 2012; 380(9851):1387-
27. Fukuta H, Goto T, Wakami K, Ohte N. Effects of
drug and exercise intervention on functional capacity
and quality of life in heart failure with preserved
ejection fraction: a meta-analysis of randomized
controlled trials. European journal of preventive cardiology
28. Poole-Wilson PA. The Cardiac Insufficiency Bisoprolol
Study II. Lancet (London, England) 1999;
29. Willenheimer R. How to begin treatment in chronic
heart failure? Results of CIBIS III. European Heart
Journal Supplements 2006; 8(suppl_C):C43-C50.
30. Willenheimer R, Erdmann E, Follath F, Krum H,
Ponikowski P, Silke B, Van Veldhuisen DJ, Van
De Ven L, Verkenne P, Lechat P. Comparison of
treatment initiation with bisoprolol vs. enalapril in
chronic heart failure patients: rationale and design
of CIBIS-III. European journal of heart failure 2004;
PDF downloads: 177
Copyright (c) 2019 Indonesian Journal of Cardiology
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).