Tuesday, April 07, 2015

Cardiorenal syndrome and decongestion in acute decompensated heart failure (ADHF)

A recent review on this topic is available as free full text here.

Here are some key points that emerge from this review:

With a few notable exceptions aggressive decongestion in ADHF improves rather than degrades renal function.

There are several mechanisms for this, described in the review.

Aggressive use of loop diuretics, traditionally considered non-evidence based, has recently been shown to be associated with improvement in important outcomes.

These outcomes include readmissions, progression of chronic heart failure and mortality. Once considered necessary for symptom relief but non-evidence based, loop diuretics are joining the ranks of the neurohumeral antagonists as evidence based for important clinical outcomes.

Some cases of “cardiorenal syndrome” may instead be due to unrecognized other causes.

Examples include ATN, interstitial nephritis, obstruction and intra-abdominal hypertension.

A diminishing role of inotropes for diuretic resistance and cardiorenal syndrome, even in the short term.

From the review:

.. inotropic agents may worsen survival over the long term, even when used temporarily; therefore, they should be avoided if possible.[37] In the OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) trial, the short-term use of milrinone increased in-hospital death and the 60-day risk of death or rehospitalization in ischemic HF, and increased arrhythmias in all HF.[38-40] Exogenous cardiac stimulation, at a time when the myocardium is significantly energy depleted, may result in further ischemic and apoptotic damage, and lead to the poor outcomes associated with these agents despite immediate short-term hemodynamic improvement. An inotrope, typically dobutamine, is still indicated temporarily in: (1) wet and cold HF with systolic blood pressure less than 85 to 90 mm Hg, or (2) wet and cold HF not responding to diuretic therapy.[41]

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