Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure

Abstract

Background Elevated lactic acid (LA) levels carry a poor prognosis in patients with shock. Data are lacking on the significance of LA levels in patients with acute decompensated heart failure (ADHF). Hypothesis This study assessed the relationship between LA levels, hemodynamics and clinical outcomes. Methods This was a retrospective analysis of registry data of 100 advanced heart failure patients presenting for right heart catheterization (RHC) for concern of ADHF. LA levels (normal ≤2.1 mmol/L) were obtained prior to RHC; no significant changes in therapy were made between LA collection and RHC. Results Median age was 58 (47.3, 64.8) years; 57% were receiving inotropes prior to RHC. Median pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were 28 (21, 35) mmHg and 2.0 (1.7, 2.5) L/min/m2, respectively. Eighty patients had normal LA prior to RHC. There was no correlation between LA levels and PCWP (R = 0.09, p = .38); 63% of the normal LA group had a PCWP >24 mmHg. There was a moderate inverse correlation between LA and CI (R = − 0.40; p < .001); 58% of the normal LA group had a CI <2.2 L/min/m2. Thirty‐day survival free of death/hospice, inotrope dependence, progression to heart transplant/left‐ventricular assist device implant was comparable between the normal and elevated LA groups (28% vs. 20%; p = .17). Conclusion In patients presenting with ADHF, normal LA levels do not exclude the presence of depressed CI (a hemodynamic criteria for cardiogenic shock) and may not offer accurate risk stratification. Invasive hemodynamics should not be delayed based on normal LA levels alone.

Predictive Value of Arterial Blood Lactic Acid Concentration on the Risk of in-Hospital All-Cause Death in Patients with Acute Heart Failure

“…Patients with AHF are unable to provide appropriate oxygenation and perfusion of tissues and organs owing to infection, decreased cardiac function, coronary artery stenosis, and other factors, increasing in anaerobic glycolysis and lactic acid build-up [ 19 ]. Narang et al revealed that cardiac index decreases when lactic acid levels rise in individuals with acute decompensated heart failure [ 7 ]. Li et al found that as lactic acid levels climbed, in-hospital mortality in patients with heart failure increased proportionately [ 20 ].…”

“…Research by Robert et al has shown that elevated blood lactic acid on admission is common in AHF patients and is associated with markers of a worse prognosis [ 6 ]. Some studies also suggest that lactic acid can predict the prognosis of patients with AHF [ 7 – 9 ]. The association between the levels of lactic acid and nosocomial all-cause mortality in patients with AHF, especially in the critical care unit, has yet to be determined.…”