Decongestion Strategies and Renin-Angiotensin-Aldosterone System Activation in Acute Heart Failure

被引：125

作者：

Mentz, Robert J. ^{[1
]}

Stevens, Susanna R. ^{[1
]}

DeVore, Adam D. ^{[1
]}

Lala, Anuradha ^{[2
,3
]}

Vader, Justin M. ^{[4
]}

AbouEzzeddine, Omar F. ^{[5
]}

Khazanie, Prateeti ^{[1
]}

Redfield, Margaret M. ^{[5
]}

Stevenson, Lynne W. ^{[2
]}

O'Connor, Christopher M. ^{[1
]}

Goldsmith, Steven R. ^{[6
]}

Bart, Bradley A. ^{[6
]}

Anstrom, Kevin J. ^{[1
]}

Hernandez, Adrian F. ^{[1
]}

Braunwald, Eugene ^{[2
]}

Felker, G. Michael ^{[1
]}

机构：

[1] Duke Clin Res Inst, Durham, NC 27710 USA

[2] Brigham & Womens Hosp, Dept Med, Div Cardiol, Boston, MA USA

[3] NYU, Sch Med, Langone Med Ctr, Dept Med,Div Cardiol, New York, NY USA

[4] Washington Univ, Sch Med, Dept Med, Div Cardiol, St Louis, MO 63110 USA

[5] Mayo Clin, Dept Med, Div Cardiol, Rochester, MN USA

[6] Hennepin Cty Med Ctr, Dept Med, Div Cardiol, Minneapolis, MN 55415 USA

来源：

JACC-HEART FAILURE | 2015年 / 3卷 / 02期

基金：

美国国家卫生研究院;

关键词：

acute heart failure; cardiorenal syndrome; decongestion; diuretics; outcomes; RAAS activation; ultrafiltration; LEFT-VENTRICULAR DYSFUNCTION; CARDIORENAL SYNDROME; FUROSEMIDE; DIURETICS; ULTRAFILTRATION; CONGESTION; TRIAL; SOLVD;

D O I：

10.1016/j.jchf.2014.09.003

中图分类号：

R5 [内科学];

学科分类号：

100201 [内科学];

摘要：

OBJECTIVES The purpose of this study was to assess the relationship between biomarkers of renin-angiotensinaldosterone system (RAAS) activation and decongestion strategies, worsening renal function, and clinical outcomes. BACKGROUND High-dose diuretic therapy in patients with acute heart failure (AHF) is thought to activate the RAAS; and alternative decongestion strategies, such as ultrafiltration (UF), have been proposed to mitigate this RAAS activation. METHODS This study analyzed 427 AHF patients enrolled in the DOSE-AHF (Diuretic Optimization Strategies in Acute Heart Failure) and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) trials. We assessed the relationship between 2 markers of RAAS activation (plasma renin activity [PRA] and aldosterone) from baseline to 72 h and 96 h and decongestion strategy: high-versus low-dose and continuous infusion versus bolus furosemide for DOSE-AHF and UF versus stepped pharmacologic care for CARRESS-HF. We determined the relationships between RAAS biomarkers and 60-day outcomes. RESULTS Patients with greater RAAS activation at baseline had lower blood pressures, lower serum sodium levels, and higher blood urea nitrogen (BUN) concentration. Continuous infusion furosemide and UF were associated with greater PRA increases (median: +1.66 vs. +0.66 ng/ml/h with continuous vs. bolus infusion, respectively, p = 0.021; +4.05 vs. +0.56 ng/ml/h with UF vs. stepped care, respectively, p = 0.014). There were no significant differences in RAAS biomarker changes with high-versus low-dose diuretic therapy (both: p > 0.5). Neither baseline log PRA nor log aldosterone was associated with increased death or HF hospitalization (hazard ratio [HR] for a doubling of 1.05; 95% confidence interval [CI]: 0.98 to 1.13; p = 0.18; and HR: 1.13; 95% CI: 0.99 to 1.28; p = 0.069, respectively). The change in RAAS biomarkers from baseline to 72 and 96 h was not associated with outcomes (both: p > 0.5). CONCLUSIONS High-dose loop diuretic therapy did not result in RAAS activation greater than that with low-dose diuretic therapy. UF resulted in greater PRA increase than stepped pharmacologic care. Neither PRA nor aldosterone was significantly associated with short-term outcomes in this cohort. (Determining Optimal Dose and Duration of Diuretic Treatment in People With Acute Heart Failure [DOSE-AHF]; NCT00577135; Effectiveness of Ultrafiltration in Treating People With Acute Decompensated Heart Failure and Cardiorenal Syndrome [CARRESS]; NCT00608491) (C) 2015 by the American College of Cardiology Foundation.

引用

页码：97 / 107

页数：11

共 22 条

[1]

SUSTAINED IMPROVEMENT IN FUNCTIONAL-CAPACITY AFTER REMOVAL OF BODY-FLUID WITH ISOLATED ULTRAFILTRATION IN CHRONIC CARDIAC-INSUFFICIENCY - FAILURE OF FUROSEMIDE TO PROVIDE THE SAME RESULT [J].