Abstract
Background
Decongestion is an important goal in the management of acute heart failure. Whether
the rate of decongestion is associated with mortality and cardiovascular outcomes
is unknown.
Methods
Using data from 4133 patients from the Efficacy of Vasopressin Antagonism in Heart
Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression
models to evaluate the association between rates of in-hospital change in assessments
of volume overload, including b-type natriuretic peptide (BNP), N-terminal pro b-type
natriuretic peptide (NT-proBNP), as well as change in hemoconcentration, with risk
of all-cause mortality and a composite outcome of cardiovascular mortality or heart
failure hospitalization.
Results
More rapid rates of in-hospital decongestion were associated with decreased risk of
mortality and the composite outcome over a median 10-month follow-up. In reference
to the quartile of slowest decline, the quartile with the fastest BNP and NT-proBNP
decline had lower hazards of mortality (hazard rate [HR] = 0.43 [0.31, 0.59] and HR = 0.27
[0.19, 0.40], respectively) and composite outcome (HR = 0.49 [0.39, 0.60] and HR = 0.54
[0.42, 0.71], respectively). In reference to the quartile of slowest increase, the
quartile with the fastest hematocrit increase had lower hazards of mortality (HR = 0.77
[0.62, 0.95]) and composite outcome (HR = 0.75 [0.64, 0.88]). Results were also consistent
when models were repeated using propensity-score matching.
Conclusions
Faster rates of decongestion are associated with reduced risk of mortality and a composite
of cardiovascular mortality and heart failure hospitalization. It remains unknown
whether more rapid decongestion provides cardiovascular benefit or whether it serves
as a proxy for less treatment resistant heart failure.
Keywords
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Article Info
Publication History
Published online: April 23, 2022
Footnotes
Funding: KL2 (TR002545-04)
Conflicts of Interest: JMT reports grants and/or personal fees from 3ive labs, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Astra Zeneca, Novartis, Cardionomic, MagentaMed, Reprieve inc., FIRE1, W.L. Gore, Sanofi, Sequana Medical, Otsuka, Abbott, Merck, Windtree Therapeutics, Lexicon pharmaceuticals, Precardia, Relypsa, Regeneron, BD, Edwards life sciences, and Lilly; and has a patent Treatment of diuretic resistance issued to Yale and Corvidia Therapeutics Inc, a patent Methods for measuring renalase issued to Yale, and a patent Treatment of diuretic resistance pending with Reprieve inc. MAK is the chair for the DSMB for BMS, and receives grant support from Otsuka and SC Pharma. JEU received grant support from Otsuka. MJS sits on the Steering Committee for Akebia with funds paid to Tufts Medical Center. WMcC, HT, MG report none.
Authorship: All authors had access to the data and a role in writing this manuscript.
Identification
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