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How to predict diuretic resistance in acutely decompensated Heart Failure patients
Session:
CO 10 - Insuficiência Cardíaca
Speaker:
Francisco Gama
Congress:
CPC 2018
Topic:
D. Heart Failure
Theme:
11. Acute Heart Failure
Subtheme:
11.4 Acute Heart Failure– Treatment
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Francisco Fernandes Gama; Afonso Félix De Oliveira; Pedro Freitas; António Tralhão; Jorge Santos Ferreira; Inês Araujo; Filipa Marques; Cândida Fonseca
Abstract
<p><strong>Background and aim:</strong> diuretic resistance is common in heart failure (HF) patients and is associated with poorer functional capacity, recurrent hospital admissions and increased mortality. However, the clinical and pathophysiologic characteristics associated with this phenomenon remain incompletely understood. We aimed to identify predictors of diuretic resistance (DR) in HF patients across the ejection fraction range.</p> <p><strong>Methods: </strong>single-center retrospective cohort study of consecutive patients admitted to a dedicated heart failure inpatient unit between January 2013 and December 2014 with a diagnosis of decompensated HF showing clinical signs of congestion requiring intravenous furosemide. DR was defined as urine output below 20 milliliters per milligram of furosemide in the first 24 hours after loop diuretic initiation. A multivariate regression logistic model was used to determine independent predictors of diuretic resistance. A ROC curve was used to determine model's discriminative power.</p> <p><strong>Results: </strong>in a population of 159 patients, mean age was 79 years (IQR 14), 46% (n=79) were male and 42% had resting symptoms. 39% (n=62) had reduced ejection fraction (defined has lower than 40%) and 46% (n=73) had ischemic etiology. Median pre-admission clearance and serum B-type NT-terminal natriuretic peptide level were 56 (Q25-75: 39.15-78.64) mL/min/1.73 m<sup>2</sup> and 8260 (P25-75: 3160-9800) pg/ml, respectively. 53% (n=84) of patients had diuretic resistance according to study definition. DR was significantly associated with cardiovascular death at 30 months median follow-up (HR 3.066 (1.21-7.79; p-value=0.019). After multivariate analysis, higher serum chloride (OR 1.18 [1.02-1.20], p=0.015), previously on oral different diuretic classes (OR 2.74 [1.04-7.27], p=0.03) and NYHA IV (OR 20.78 [8.04-53.71], p<0.001) emerged as independent predictors of DR. This 3-variable model had good discriminative power (c-statistic = 0.85, [0.79-0.91], p<0.001) as shown in graphic 1.</p> <p><strong>Conclusions: </strong>in a population of patients requiring hospital admission for decompensated HF, diuretic resistance was common. NYHA IV, previous oral diuretic association and hyperchloremia were independent predictors of DR. A simple model including two clinical variables and a single laboratory value presented a good predictive accuracy of diuretic resistance and may anticipate appropriate therapies.</p>
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