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Hemoconcentration-guided Diuresis in Heart Failure

      Abstract

      One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps related to ineffective decongestion. Limited data exist guiding the extent and duration of diuresis in patients hospitalized for heart failure. The objective of this review was to determine the prognostic value of hemoconcentration, or the relative increase in the cellular elements in blood, in patients hospitalized for heart failure and to clarify its role in guiding inpatient diuretic practices. Six post hoc retrospective studies from 2010 to 2013 were available for review. Hemoconcentration was consistently associated with markers of aggressive fluid removal, including higher diuretic dosing and reduced body weight, but increased risk of in-hospital worsening renal function. Despite this, hemoconcentration was associated with improved short-term mortality and rehospitalization. Hemoconcentration is a practical, readily available, noninvasive, economically feasible strategy to help guide diuresis and monitor congestion relief in patients hospitalized for worsening heart failure. Clinicians should strongly consider using changes in hemoglobin and hematocrit as an adjunct to other available measures of decongestion and clinical acumen in inpatient heart failure care.

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      References

        • Gheorghiade M.
        • Vaduganathan M.
        • Fonarow G.C.
        • Bonow R.O.
        Rehospitalization for heart failure: problems and perspectives.
        J Am Coll Cardiol. 2013; 61: 391-403
        • Adams Jr., K.F.
        • Fonarow G.C.
        • Emerman C.L.
        • et al.
        Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE).
        Am Heart J. 2005; 149: 209-216
        • Fonarow G.C.
        • Stough W.G.
        • Abraham W.T.
        • et al.
        Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry.
        J Am Coll Cardiol. 2007; 50: 768-777
        • Bueno H.
        • Ross J.S.
        • Wang Y.
        • et al.
        Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006.
        JAMA. 2010; 303: 2141-2147
        • Dharmarajan K.
        • Hsieh A.F.
        • Lin Z.
        • et al.
        Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        JAMA. 2013; 309: 355-363
        • Metra M.
        • O'Connor C.M.
        • Davison B.A.
        • et al.
        Early dyspnoea relief in acute heart failure: prevalence, association with mortality, and effect of rolofylline in the PROTECT Study.
        Eur Heart J. 2011; 32: 1519-1534
        • O'Connor C.M.
        • Stough W.G.
        • Gallup D.S.
        • et al.
        Demographics, clinical characteristics, and outcomes of patients hospitalized for decompensated heart failure: observations from the IMPACT-HF registry.
        J Card Fail. 2005; 11: 200-205
        • Vaduganathan M.
        • Bonow R.O.
        • Gheorghiade M.
        Thirty-day readmissions: the clock is ticking.
        JAMA. 2013; 309: 345-346
        • Bart B.A.
        • Goldsmith S.R.
        • Lee K.L.
        • et al.
        Ultrafiltration in decompensated heart failure with cardiorenal syndrome.
        N Engl J Med. 2012; 367: 2296-2304
        • Felker G.M.
        • Mentz R.J.
        Diuretics and ultrafiltration in acute decompensated heart failure.
        J Am Coll Cardiol. 2012; 59: 2145-2153
        • Januzzi J.L.
        • Troughton R.
        Are serial BNP measurements useful in heart failure management? Serial natriuretic peptide measurements are useful in heart failure management.
        Circulation. 2013; 127: 500-508
        • Gheorghiade M.
        • Follath F.
        • Ponikowski P.
        • et al.
        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.
        Eur J Heart Fail. 2010; 12: 423-433
        • Blair J.E.
        • Pang P.S.
        • Schrier R.W.
        • et al.
        Changes in renal function during hospitalization and soon after discharge in patients admitted for worsening heart failure in the placebo group of the EVEREST trial.
        Eur Heart J. 2011; 32: 2563-2572
        • Blair J.E.
        • Khan S.
        • Konstam M.A.
        • et al.
        Weight changes after hospitalization for worsening heart failure and subsequent re-hospitalization and mortality in the EVEREST trial.
        Eur Heart J. 2009; 30: 1666-1673
        • Kociol R.D.
        • McNulty S.E.
        • Hernandez A.F.
        • et al.
        Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure.
        Circ Heart Fail. 2013; 6: 240-245
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 62: e147-e239
        • Wang C.S.
        • FitzGerald J.M.
        • Schulzer M.
        • et al.
        Does this dyspneic patient in the emergency department have congestive heart failure?.
        JAMA. 2005; 294: 1944-1956
        • Ambrosy A.P.
        • Pang P.S.
        • Khan S.
        • et al.
        Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial.
        Eur Heart J. 2013; 34: 835-843
        • Cotter G.
        • Metra M.
        • Milo-Cotter O.
        • et al.
        Fluid overload in acute heart failure–re-distribution and other mechanisms beyond fluid accumulation.
        Eur J Heart Fail. 2008; 10: 165-169
        • Testani J.M.
        • Brisco M.A.
        • Turner J.M.
        • et al.
        Loop diuretic efficiency: a metric of diuretic responsiveness with prognostic importance in acute decompensated heart failure.
        Circ Heart Fail. 2014; 7: 261-270
        • Valente M.A.
        • Voors A.A.
        • Damman K.
        • et al.
        Diuretic response in acute heart failure: clinical characteristics and prognostic significance.
        Eur Heart J. 2014; 35: 1284-1293
        • Binanay C.
        • Califf R.M.
        • Hasselblad V.
        • et al.
        Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial.
        JAMA. 2005; 294: 1625-1633
        • Bayes-Genis A.
        • Pascual-Figal D.
        • Fabregat J.
        • et al.
        Serial NT-proBNP monitoring and outcomes in outpatients with decompensation of heart failure.
        Int J Cardiol. 2007; 120: 338-343
        • Bettencourt P.
        • Azevedo A.
        • Pimenta J.
        • et al.
        N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients.
        Circulation. 2004; 110: 2168-2174
        • Singer A.J.
        • Birkhahn R.H.
        • Guss D.
        • et al.
        Rapid Emergency Department Heart Failure Outpatients Trial (REDHOT II): a randomized controlled trial of the effect of serial B-type natriuretic peptide testing on patient management.
        Circ Heart Fail. 2009; 2: 287-293
        • Morello A.
        • Lloyd-Jones D.M.
        • Chae C.U.
        • et al.
        Association of atrial fibrillation and amino-terminal pro-brain natriuretic peptide concentrations in dyspneic subjects with and without acute heart failure: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study.
        Am Heart J. 2007; 153: 90-97
        • Kociol R.D.
        • Pang P.S.
        • Gheorghiade M.
        • et al.
        Troponin elevation in heart failure prevalence, mechanisms, and clinical implications.
        J Am Coll Cardiol. 2010; 56: 1071-1078
        • Anwaruddin S.
        • Lloyd-Jones D.M.
        • Baggish A.
        • et al.
        Renal function, congestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study.
        J Am Coll Cardiol. 2006; 47: 91-97
        • Gheorghiade M.
        • Bohm M.
        • Greene S.J.
        • et al.
        Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure: the ASTRONAUT randomized trial.
        JAMA. 2013; 309: 1125-1135
        • Brandimarte F.
        • Vaduganathan M.
        • Mureddu G.F.
        • et al.
        Prognostic implications of renal dysfunction in patients hospitalized with heart failure: data from the last decade of clinical investigations.
        Heart Fail Rev. 2013; 18: 167-176
        • Givertz M.M.
        • Postmus D.
        • Hillege H.L.
        • et al.
        Renal function trajectories and clinical outcomes in acute heart failure.
        Circ Heart Fail. 2014; 7: 59-67
        • Testani J.M.
        • McCauley B.D.
        • Chen J.
        • et al.
        Clinical characteristics and outcomes of patients with improvement in renal function during the treatment of decompensated heart failure.
        J Card Fail. 2011; 17: 993-1000
        • Baillargeon J.D.
        • Orav J.
        • Ramagopal V.
        • et al.
        Hemoconcentration as an early risk factor for necrotizing pancreatitis.
        Am J Gastroenterol. 1998; 93: 2130-2134
        • Boyle A.
        • Sobotka P.A.
        Redefining the therapeutic objective in decompensated heart failure: hemoconcentration as a surrogate for plasma refill rate.
        J Card Fail. 2006; 12: 247-249
        • Testani J.M.
        • Chen J.
        • McCauley B.D.
        • et al.
        Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival.
        Circulation. 2010; 122: 265-272
        • Davila C.
        • Reyentovich A.
        • Katz S.D.
        Clinical correlates of hemoconcentration during hospitalization for acute decompensated heart failure.
        J Card Fail. 2011; 17: 1018-1022
        • van der Meer P.
        • Postmus D.
        • Ponikowski P.
        • et al.
        The predictive value of short-term changes in hemoglobin concentration in patients presenting with acute decompensated heart failure.
        J Am Coll Cardiol. 2013; 61: 1973-1981
        • Greene S.J.
        • Gheorghiade M.
        • Vaduganathan M.
        • et al.
        Haemoconcentration, renal function, and post-discharge outcomes among patients hospitalized for heart failure with reduced ejection fraction: insights from the EVEREST trial.
        Eur J Heart Fail. 2013; 15: 1401-1411
        • Oh J.
        • Kang S.M.
        • Hong N.
        • et al.
        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: 4739-4743
        • Testani J.M.
        • Brisco M.A.
        • Chen J.
        • et al.
        Timing of hemoconcentration during treatment of acute decompensated heart failure and subsequent survival: importance of sustained decongestion.
        J Am Coll Cardiol. 2013; 62: 516-524
        • Konishi M.
        • Matsuzawa Y.
        • Suzuki H.
        • et al.
        Higher level at admission and subsequent decline in hemoglobin in patients with acute pulmonary edema.
        Circ J. 2014; 78: 896-902
        • Adlbrecht C.
        • Kommata S.
        • Hulsmann M.
        • et al.
        Chronic heart failure leads to an expanded plasma volume and pseudoanaemia, but does not lead to a reduction in the body's red cell volume.
        Eur Heart J. 2008; 29: 2343-2350
        • Pitt B.
        • Gheorghiade M.
        Vasopressin V1 receptor-mediated aldosterone production as a result of selective V2 receptor antagonism: a potential explanation for the failure of tolvaptan to reduce cardiovascular outcomes in the EVEREST trial.
        Eur J Heart Fail. 2011; 13: 1261-1263