Enhanced Decongestive Therapy in Patients With Acute Heart Failure

Cotter, Gad; Davison, Beth; Chioncel, Ovidiu

doi:10.1016/j.jacc.2024.01.029

Cited by 8 publications

(2 citation statements)

References 44 publications

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“…27 The reasons for such modest associations are not known; however, it is possible that congestion by itself is a symptom of HF but not its main pathophysiological cause and, therefore, the presence of congestion is not a strong predictor of adverse outcomes post-discharge from an acute HF admission. 13 Hence, bio-ADM and NT-proBNP, which are markers of congestion, are equally only modest predictors of adverse outcomes. This issue is compounded by the fact that HF readmissions are not always determined only by HF severity and some are related to socioeconomical and other non-cardiovascular causes (such as frailty) further reducing the association between congestion and its markers and outcomes after acute HF.…”

Section: Additive Value Of Biologically Active Adrenomedullin To Nt-p...mentioning

confidence: 99%

“…[10][11][12] Optimal treatment to relieve congestion is currently under discussion. 8,13 Although decongestion with loop diuretics remains the first choice during the early phases of a HF hospitalization, data from STRONG-HF have shown that early initiation and fast up-titration of GDMT not only reduces congestion but improves clinical outcomes as well. However, the potential role of bio-ADM in the selection of patients that might need more aggressive decongestion remains to be established.…”

Section: Introductionmentioning

confidence: 99%

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Biologically active adrenomedullin as a marker for residual congestion and early rehospitalization in patients hospitalized for acute heart failure: Data from STRONG‐HF

Voordes,

Davison,

Biegus

et al. 2024

European J of Heart Fail

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AimsBiologically active adrenomedullin (bio‐ADM) is a promising marker of residual congestion. The STRONG‐HF trial showed that high‐intensity care (HIC) of guideline‐directed medical therapy (GDMT) improved congestion and clinical outcomes in heart failure (HF) patients. The association between bio‐ADM, decongestion, outcomes and the effect size of HIC of GDMT remains to be elucidated.Methods and resultsWe measured plasma bio‐ADM concentrations in 1005 patients within 2 days prior to anticipated discharge (baseline) and 90 days later. Bio‐ADM correlated with most signs of congestion, with the exception of rales. Changes in bio‐ADM were strongly correlated with change in congestion status from baseline to day 90 (gamma −0.24; p = 0.0001). Patients in the highest tertile of baseline bio‐ADM concentrations were at greater risk than patients in the lowest tertile for the primary outcome of 180‐day all‐cause mortality or HF rehospitalization (hazard ratio [HR] 2.14, 95% confidence interval [CI] 1.42–3.22) and 180‐day HF rehospitalization (HR 2.33, 95% CI 1.38–3.94). Areas under the receiver‐operating characteristic curves were 0.5977 (95% CI 0.5561–0.6393), 0.5800 (95% CI 0.5356–0.6243), and 0.6159 (95% CI 0.5711–0.6607) for bio‐ADM, N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) and their combination, respectively, suggesting that both bio‐ADM and NT‐proBNP provided similarly modest discrimination for this outcome. A trend towards better discrimination by combined bio‐ADM and NT‐proBNP than NT‐proBNP alone was found (p = 0.059). HIC improved the primary outcome, irrespective of baseline bio‐ADM concentration (interaction p = 0.37). In contrast to NT‐proBNP, the 90‐day change in bio‐ADM did not differ significantly between HIC and usual care.ConclusionsBio‐ADM is a marker of congestion and predicts congestion at 3 months after a HF hospitalization. Higher bio‐ADM was modestly associated with a higher risk of death and early hospital readmission and may have added value when combined with NT‐proBNP.

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Section: Additive Value Of Biologically Active Adrenomedullin To Nt-p...mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Biologically active adrenomedullin as a marker for residual congestion and early rehospitalization in patients hospitalized for acute heart failure: Data from STRONG‐HF

Voordes,

Davison,

Biegus

et al. 2024

European J of Heart Fail

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High-intensity care for GDMT titration

Biegus,

Pagnesi,

Davison

et al. 2024

Heart Fail Rev

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Heart failure (HF) is a systemic disease associated with a high risk of morbidity, mortality, increased risk of hospitalizations, and low quality of life. Therefore, effective, systemic treatment strategies are necessary to mitigate these risks. In this manuscript, we emphasize the concept of high-intensity care to optimize guideline-directed medical therapy (GDMT) in HF patients. The document highlights the importance of achieving optimal recommended doses of GDMT medications, including beta-blockers, renin–angiotensin–aldosterone inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors to improve patient outcomes, achieve effective, sustainable decongestion, and improve patient quality of life. The document also discusses potential obstacles to GDMT optimization, such as clinical inertia, physiological limitations, comorbidities, non-adherence, and frailty. Lastly, it also attempts to provide possible future scenarios of high-intensive care that could improve patient outcomes.

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