Markers of diuretic resistance in emergency department patients with acute heart failure

被引：46

作者：

Doering A. ^{[1
]}

Jenkins C.A. ^{[2
]}

Storrow A.B. ^{[1
]}

Lindenfeld J.A. ^{[3
]}

Fermann G.J. ^{[4
]}

Miller K.F. ^{[1
]}

Sperling M. ^{[4
]}

Collins S.P. ^{[1
]}

机构：

[1] Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

[2] Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN

[3] Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN

[4] Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH

来源：

International Journal of Emergency Medicine | 2017年 / 10卷 / 1期

关键词：

Acute heart failure; Diuretic resistance; Emergency department;

D O I：

10.1186/s12245-017-0143-x

中图分类号：

学科分类号：

摘要：

Background: Loop diuretics are common therapy for emergency department (ED) patients with acute heart failure (AHF). Diuretic resistance (DR) is a term used to describe blunted natriuretic response to loop diuretics. It would be important to detect DR prior to it becoming clinically apparent, so early interventions can be initiated. However, several definitions have been proposed, and it is not clear if they identify similar patients. We compared these definitions and described the clinical characteristics of patients who fulfilled them. Methods: To qualify for this secondary analysis of 1033 ED patients with AHF, all patients needed to receive intravenous diuretics in the ED and have urine available within 24 h of their ED evaluation. A poor diuretic response, suggesting DR, was characterized by (1) a fractional sodium excretion (FeNa) of less than 0.2%; (2) spot urinary sodium of less than 50 meq/L; and (3) a urinary Na/K ratio <1.0. McNemar’s test was used to compare the different cohorts identified by the three definitions. Secondary analyses evaluated associations between each DR definition and hospital length of stay (LOS), ED revisits and rehospitalizations for AHF, and mortality using the Wilcoxon rank-sum tests and linear regression or Pearson chi-square test and logistic regression, as appropriate. Results: The median age of the 187 patients was 64, and 50% were African-American. There were 5.9% of patients with a FeNa less than 0.2%, 17.1% had urinary sodium less than 50 meq/L, and 10.7% had a urinary Na/K ratio <1.0. The three definitions identified significantly different patients with very little overlap (p < 0.02 for all comparisons). There were 37 (19.8%) patients who were readmitted to the ED or hospital or died within 30 days of ED evaluation. Patients with spot urinary sodium less than 50 meq/L were more likely to be readmitted (p = 0.03). Conclusions: The patient proportion with poor natriuresis and DR varies depending on the definition used. Early ED therapy would be impacted at different rates if clinical decisions are made based on these definitions. These findings need to be further explored in a prospective ED-based study. Trial registration: ClinicalTrials.gov, NCT00508638. © 2017, The Author(s).

引用

共 20 条

[1]

Storrow A.B., Jenkins C.A., Self W.H., Alexander P.T., Barrett T.W., Han J.H., Et al., The burden of acute heart failure on U.S. emergency departments, JACC Heart fail, 2, 3, pp. 269-277, (2014)

[2]

Collins S.P., Jenkins C.A., Harrell F.E., Liu D., Miller K.F., Lindsell C.J., Et al., Identification of emergency department patients with acute heart failure at low risk for 30-day adverse events: the STRATIFY decision tool, JACC Heart fail, 3, 10, pp. 737-747, (2015)

[3]

Adams K.F., Fonarow G.C., Emerman C.L., LeJemtel T.H., Costanzo M.R., Abraham W.T., 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, 149, 2, pp. 209-216, (2005)

[4]

Felker G.M., Lee K.L., Bull D.A., Redfield M.M., Stevenson L.W., Goldsmith S.R., Et al., Diuretic strategies in patients with acute decompensated heart failure, N Engl J Med, 364, 9, pp. 797-805, (2011)

[5]

ter Maaten J.M., Valente M.A., Damman K., Hillege H.L., Navis G., Voors A.A., Diuretic response in acute heart failure-pathophysiology, evaluation, and therapy, Nat Rev Cardiol, 12, 3, pp. 184-192, (2015)

[6]

Braunwald E., Plauth W.H., Morrow A.G., A method for the detection and quantification of impaired sodium excretion. Results of an oral sodium tolerance test in normal subjects and in patients with heart disease, Circulation, 32, pp. 223-231, (1965)

[7]

Ter Maaten J.M., Valente M.A., Damman K., Hillege H.L., Navis G., Voors A.A., Diuretic response in acute heart failure-pathophysiology, evaluation, and therapy, Nat Rev Cardiol., (2015)

[8]

ter Maaten J.M., Dunning A.M., Valente M.A., Damman K., Ezekowitz J.A., Califf R.M., Et al., Diuretic response in acute heart failure—an analysis from ASCEND-HF, Am Heart J, 170, 2, pp. 313-321, (2015)

[9]

Voors A.A., Davison B.A., Teerlink J.R., Felker G.M., Cotter G., Filippatos G., Et al., Diuretic response in patients with acute decompensated heart failure: characteristics and clinical outcome—an analysis from RELAX-AHF, Eur J Heart Fail, 16, 11, pp. 1230-1240, (2014)

[10]

Testani J.M., Hanberg J.S., Cheng S., Rao V., Onyebeke C., Laur O., Et al., Rapid and highly accurate prediction of poor loop diuretic natriuretic response in patients with heart failure, Circ Heart Fail, 9, 1, (2016)

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