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Heart Failure Outcomes With Volume-Guided Management
Study Questions:
What is the impact of direct quantitative volume measurement on short- and long-term all-cause mortality, 30-day rehospitalizations, and length of stay for patients admitted with acute heart failure (HF)?
Methods:
The investigators performed a propensity score control matching analysis in 245 consecutive HF admissions, representing 177 unique patients, to a community hospital (September 2007-April 2014; 78 ± 10 years of age; 50% with HF with reduced ejection fraction [HFrEF]; and 30% with Stage 4 chronic kidney disease). Total blood volume (TBV), red blood cell volume (RBCV), and plasma volume (PV) were measured at admission by using iodine-131-labeled serum albumin indicator-dilution technique. Decongestion strategy targeted a TBV threshold of 6% to 8% above patient-specific normative values. Anemia (hemoglobin <8 g/dl) was treated based on cause. Hematocrit (Hct) measurements were monitored to assess effectiveness of interventions. Control subjects (n = 2,450) derived from Centers for Medicare and Medicaid Services data were matched 10:1 for demographics, comorbidity, and year of therapy.
Results:
The investigators found that 66% of subjects had PV expansion, and only 37% were hypervolemic (TBV >10% excess). True anemia (RBCV ≥10% deficit) was present in 62% of subjects. Treatment of true anemia without hypervolemia resulted in a rise in peripheral Hct of 2.7 ± 2.9% (p < 0.001), and diuretic treatment of hypervolemia in cases without anemia caused a 4.5 ± 3.9% (p < 0.001) increase in peripheral Hct at 11.3 ± 7.5 days after admission. Subjects had lower 30-day rates of readmission (12.2% vs. 27.7%, respectively; p < 0.001), of 30-day mortality (2.0% vs. 11.1%, respectively; p < 0.001), and of 365-day mortality (4.9% vs. 35.5%, respectively; p < 0.001), but longer lengths of stay (7.3 vs. 5.6 days, respectively; p < 0.001) than control subjects. High heterogeneity in volume status was observed across EF subsets, and both HF with HFrEF and HFpEF had better outcomes than control subjects (p < 0.001). HF with preserved EF (HFpEF) outcomes were numerically but not statistically superior to those for HFrEF. The 30-day readmission rates for HFpEF versus those for HFrEF were 9.8% versus 14.6%, respectively (p = 0.253), 30-day mortality rate 0.8% versus 3.3%, respectively (p = 0.179), and 365-day mortality rates were 4.1% versus 5.7%, respectively (p = 0.565).
Conclusions:
The study authors concluded that using volume-guided HF therapy versus propensity-matched controls support the benefit of BVA in guiding volume management and reducing death and rehospitalization due to HF.
Perspective:
We all know that achieving dry weight in HF patients is desirable, but achieving this is often a challenge, particularly in the setting of cardiorenal syndrome and obesity. This retrospective analysis suggests that volume-guided therapy for HF reduces both mortality and rehospitalizations. Prospective studies are now needed to confirm these important findings.
Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure, Chronic Heart Failure
Keywords: Anemia, Blood Volume Determination, Cardio-Renal Syndrome, Centers for Medicare and Medicaid Services, U.S., Diuretics, Erythrocyte Volume, Geriatrics, Heart Failure, Hematocrit, Hemoglobins, Indicator Dilution Techniques, Iodine Radioisotopes, Plasma Volume, Renal Insufficiency, Chronic, Serum Albumin, Stroke Volume
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