Impact of changes in blood pressure during the treatment of acute decompensated heart failure on renal and clinical outcomes

• Published in: European journal of heart failure Vol. 13; no. 8; pp. 877 - 884
• Main Authors: Testani, Jeffrey M., Coca, Steven G., McCauley, Brian D., Shannon, Richard P., Kimmel, Stephen E.
• Format: Journal Article
• Language: English
• Published: England Blackwell Publishing Ltd 01.08.2011; Oxford University Press
• Subjects: Acute Disease; Adult; Aged; Blood pressure; Blood Pressure - drug effects; Cardio-renal syndrome; Comorbidities; Decompensated heart failure; Female; Glomerular Filtration Rate - drug effects; Heart Failure - physiopathology; Heart Failure - therapy; Humans; Kidney; Kidney - blood supply; Kidney - drug effects; Kidney - physiopathology; Kidney Diseases - physiopathology; Kidney Function Tests; Male; Middle Aged; Prognosis; Treatment Outcome; Worsening renal function; Cardio-renal syndrome; Blood pressure; Worsening renal function; Decompensated heart failure; Kidney
• ISSN: 1388-9842; 1879-0844; 1879-0844
• DOI: 10.1093/eurjhf/hfr070

Aims One of the primary determinants of blood flow in regional vascular beds is perfusion pressure. Our aim was to investigate if reduction in blood pressure during the treatment of decompensated heart failure would be associated with worsening renal function (WRF). Our secondary aim was to evaluate the prognostic significance of this potentially treatment-induced form of WRF. Methods and results Subjects included in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial limited data were studied (386 patients). Reduction in systolic blood pressure (SBP) was greater in patients experiencing WRF (−10.3 ± 18.5 vs. −2.8 ± 16.0 mmHg, P < 0.001) with larger reductions associated with greater odds for WRF (odds ratio = 1.3 per 10 mmHg reduction, P < 0.001). Systolic blood pressure reduction (relative change > median) was associated with greater doses of in-hospital oral vasodilators (P ≤ 0.017), thiazide diuretic use (P = 0.035), and greater weight reduction (P = 0.023). In patients with SBP-reduction, WRF was not associated with worsened survival [adjusted hazard ratio (HR) = 0.76, P = 0.58]. However, in patients without SBP-reduction, WRF was strongly associated with increased mortality (adjusted HR = 5.3, P < 0.001, P interaction = 0.001). Conclusion During the treatment of decompensated heart failure, significant blood pressure reduction is strongly associated with WRF. However, WRF that occurs in the setting of SBP-reduction is not associated with an adverse prognosis, whereas WRF in the absence of this provocation is strongly associated with increased mortality. These data suggest that WRF may represent the final common pathway of several mechanistically distinct processes, each with potentially different prognostic implications.