Multi‐organ dysfunction/injury on admission identifies acute heart failure patients at high risk of poor outcome

Abstract

Background Clinical consequences of an interplay between dysfunction/injury of different end‐organs in acute heart failure (AHF) remain unknown. Methods and results In 284 consecutive AHF patients, end‐organ dysfunction/injury was defined as cardiac [troponin I level above the upper reference limit (URL, > 0.056 ng/mL)], kidney (estimated glomerular filtration rate < 60 mL/min/1.73 m2), and liver [at least one of the following: aspartate transaminase (AST)/alanine transaminase (ALT) > 3 times the URL (> 114 IU/L and > 105 IU/L for AST and ALT, respectively), bilirubin above the URL (> 1.3 mg/mL), albumin below the lower reference limit (< 3.5 mg/dL)]. The primary endpoints were early (within first 48 h) in‐hospital worsening of heart failure and 1‐year all‐cause mortality. On admission, cardiac, kidney, liver dysfunction/injury were present in 38%, 50%, and 54% of patients, respectively. Patients were classified as having 0, 1, 2, or 3 organ injury/dysfunction (17%, 36%, 35%, and 12% of patients, respectively). Baseline clinical characteristics and co‐morbidity profile were similar across groups. Patients with three organ dysfunction/injury had the worst 1‐year survival rate [46%; hazard ratio (HR) with 95% confidence interval (CI) vs. patients without organ dysfunction: 6.75 (2.52–18.13), those with two (67%; HR 3.54, 95% CI 1.38–9.08), one (84%; HR 1.58, 95% CI 0.58–4.30), or no organ dysfunction/injury (90%); P < 0.01]. Worsening of heart failure was more frequent in patients with three and two vs. those with one or no organ dysfunction/injury (37% vs. 38% vs. 23% vs. 21%, P < 0.05). Conclusions In patients with AHF, dysfunction/injury of > 1 end‐organ dysfunction/injury identifies patients at the highest risk of poor outcomes.

Hepatorenal dysfunction identifies high‐risk patients with acute heart failure: insights from the RELAX‐AHF trial

“…27 Analogically to present analyses, the dysfunction of two organs (kidney, liver, or heart) was related to 3.5-fold higher 1 year mortality. We have demonstrated that any elevation of MELD-XI defined as being above the minimal value (which is 9.44 points) had prognostic significance.…”

“…This observation goes with agreement with recently published data, in which AHF patients presenting with higher number of dysfunctional/injured organs on admission had much worse outcome, than had those with lower numbers or no signs of dysfunction. 27 Analogically to present analyses, the dysfunction of two organs (kidney, liver, or heart) was related to 3.5-fold higher 1 year mortality. 27 Coexistence of hepatorenal dysfunction identified patients with more advanced heart failure (as evidenced by lower ejection fraction, lower systolic blood pressure, higher NT-proBNP, higher rate of history of chronic heart failure, and higher rates of oedema), but the association with poor outcomes remained highly statistically significant after multivariable adjustment.…”

“…27 Analogically to present analyses, the dysfunction of two organs (kidney, liver, or heart) was related to 3.5-fold higher 1 year mortality. 27 Coexistence of hepatorenal dysfunction identified patients with more advanced heart failure (as evidenced by lower ejection fraction, lower systolic blood pressure, higher NT-proBNP, higher rate of history of chronic heart failure, and higher rates of oedema), but the association with poor outcomes remained highly statistically significant after multivariable adjustment. Importantly, there were no obvious clinical signs identifying patients with hepatorenal dysfunction on admission.…”

“…This observation seems somehow counterintuitive to the traditional view of organ dysfunction in AHF, as we believe that mechanisms leading to or underlying decompensation of heart failure may also lead to functional deterioration of other organs. 27 Thus, one would rather expect the number of patients with organ dysfunction to decrease during the post-discharge phase.…”

Highlights in heart failure

“…15, [216][217][218] Multiple factors may contribute to the poor outcomes of the patients after the hospitalization for acute HF, including socioeconomic factors, poor patient support, and poor adherence to prescribed medications. 24, [223][224][225][226][227] Unfortunately, strategies aimed at a better medical treatment of the acute phase, have failed to improve outcomes in major multicentre trials. 222 Other mechanisms are more directly related with congestion and possibly with myocardial, renal, and hepatic injury with persistent organ dysfunction.…”