ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference

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Abstract

Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.

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Most cited references 103

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The effect of digoxin on mortality and morbidity in patients with heart failure.

(1997)

The role of cardiac glycosides in treating patients with chronic heart failure and normal sinus rhythm remains controversial. We studied the effect of digoxin on mortality and hospitalization in a randomized, double-blind clinical trial. In the main trial, patients with a left ventricular ejection fraction of 0.45 or less were randomly assigned to digoxin (3397 patients) or placebo (3403 patients) in addition to diuretics and angiotensin-converting-enzyme inhibitors (median dose of digoxin, 0.25 mg per day; average follow-up, 37 months). In an ancillary trial of patients with ejection fractions greater than 0.45, 492 patients were randomly assigned to digoxin and 496 to placebo. In the main trial, mortality was unaffected. There were 1181 deaths (34.8 percent) with digoxin and 1194 deaths (35.1 percent) with placebo (risk ratio when digoxin was compared with placebo, 0.99; 95 percent confidence interval, 0.91 to 1.07; P=0.80). In the digoxin group, there was a trend toward a decrease in the risk of death attributed to worsening heart failure (risk ratio, 0.88; 95 percent confidence interval, 0.77 to 1.01; P=0.06). There were 6 percent fewer hospitalizations overall in that group than in the placebo group, and fewer patients were hospitalized for worsening heart failure (26.8 percent vs. 34.7 percent; risk ratio, 0.72; 95 percent confidence interval, 0.66 to 0.79; P<0.001). In the ancillary trial, the findings regarding the primary combined outcome of death or hospitalization due to worsening heart failure were consistent with the results of the main trial. Digoxin did not reduce overall mortality, but it reduced the rate of hospitalization both overall and for worsening heart failure. These findings define more precisely the role of digoxin in the management of chronic heart failure.

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ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).

Kenneth Dickstein, Alain Cohen-Solal, Gerasimos Filippatos … (2008)

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Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry.

Gregg C. Fonarow, Wendy Stough, William T. Abraham … (2007)

We sought to evaluate the characteristics, treatments, and outcomes of patients with preserved and reduced systolic function heart failure (HF). Heart failure with preserved systolic function (PSF) is common but not well understood. This analysis of the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry compared 20,118 patients with left ventricular systolic dysfunction (LVSD) and 21,149 patients with PSF (left ventricular ejection fraction [EF] > or =40%). Sixty- to 90-day follow-up was obtained in a pre-specified 10% sample of patients. Analyses of patients with PSF defined as EF >50% were also performed for comparison. Patients with PSF (EF > or =40%) were more likely to be older, female, and Caucasian and to have a nonischemic etiology. Although length of hospital stay was the same in both groups, risk of in-hospital mortality was lower in patients with PSF (EF > or =40%) (2.9% vs. 3.9%; p or =40%) had a similar mortality risk (9.5% vs. 9.8%; p = 0.459) and rehospitalization rates (29.2% vs. 29.9%; p = 0.591) compared with patients with LVSD. Findings were comparable with those with PSF defined as EF >50%. In a risk- and propensity-adjusted model, there were no significant relationships between discharge use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or beta-blocker and 60- to 90-day mortality and rehospitalization rates in patients with PSF. Data from the OPTIMIZE-HF registry reveal a high prevalence of HF with PSF, and these patients have a similar post-discharge mortality risk and equally high rates of rehospitalization as patients with HF and LVSD. Despite the burden to patients and health care systems, data are lacking on effective management strategies for patients with HF and PSF. (Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure [OPTIMIZE-HF]); http://www.clinicaltrials.gov/ct/show/NCT00344513?order=1; NCT00344513).