Outcomes of Patients With Chronic Heart Failure and Septic Shock

Gabra, Nader Ishak; Kim, Boram; Iyengar, Rupa; Duttuluri, Manideep; Lee, Sung; Pan, Di; Khouli, Hassan; Mathew, Joseph

doi:10.1016/j.chest.2017.08.403

Cited by 5 publications

(5 citation statements)

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“…The core management of sepsis seems to be a paradox in patients with HF as the fluid bolus and vasoactive agents required in sepsis raise concerns in the context of cardiac dysfunction in such cases ( 21 ). These patients have worse clinical outcomes ( 22 ), even after hospital discharge ( 23 ). However, there is limited evidence on the influence of fluid resuscitation on the outcomes of patients with sepsis with pre-existing HF ( 21 ).…”

Section: Discussionmentioning

confidence: 99%

Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study

Dong

Gao

et al. 2022

Front. Med.

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Sepsis management includes intravenous fluid (IVF) resuscitation, but patients with pre-existing congestive heart failure (CHF) have a higher risk of fluid overload. Further, patients with sepsis with concomitant CHF present worse clinical outcomes. Nevertheless, there is limited evidence of the association between fluid management and the outcomes of patients with concomitant sepsis and CHF. This retrospective cohort study aimed to evaluate the association between fluid management and in-hospital mortality in patients with sepsis and concomitant heart failure (HF). The patients' data were extracted from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was in-hospital mortality. A restricted cubic spline model was used to explore the relationship between variables and in-hospital mortality. Logistic models were built using the linear spline function and design variables to investigate the association of fluid balance (FB), fluid intake (FI), and fluid accumulation index (FAI, calculated as the FB/FI ratio) with mortality. Overall, 1,801 patients were included. The overall mortality rate was 27.7%. After adjusting for confounding variables, FAI was found to be associated with in-hospital mortality, whereas FB and FI were not. With FAI values of 0–0.42 set as references, FAI values <0 were not associated with in-hospital mortality [odds ratio (OR): 1.078; 95% confidence interval (CI): 0.774–1.503], whereas FAI values > 0.42 were significantly associated with higher in-hospital mortality (OR: 1.461; 95% CI: 1.099–1.954). High FAI values (>0.42) were associated with high in-hospital mortality in patients with sepsis with HF, while FB and FI were not. Proper fluid management may improve the outcomes of patients with sepsis and concomitant HF.

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Section: Discussionmentioning

confidence: 99%

Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study

Dong

Gao

et al. 2022

Front. Med.

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“…Prior studies have reached variable conclusions about the association of HFrEF with mortality among patients with sepsis, with some studies showing no association and others showing increased mortality among patients with HFrEF. 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 31 , 32 One potential explanation for these variable findings is the inconsistency in how heart failure is defined. Many groups rely on administrative billing codes to define HFrEF; these codes may have poor sensitivity and positive predictive value.…”

Section: Discussionmentioning

confidence: 99%

“…These results also show that differences in fluid administration practice patterns are not associated with different clinical outcomes, even among patients with preexisting HFrEF. Prior studies have reached variable conclusions about the association of HFrEF with mortality among patients with sepsis, with some studies showing no association and others showing increased mortality among patients with HFrEF . One potential explanation for these variable findings is the inconsistency in how heart failure is defined.…”

Section: Discussionmentioning

confidence: 99%

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

et al. 2022

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ImportanceIntravenous fluid administration is recommended to improve outcomes for patients with septic shock. However, there are few data on fluid administration for patients with preexisting heart failure with reduced ejection fraction (HFrEF).ObjectiveTo evaluate the association between preexisting HFrEF, guideline-recommended intravenous fluid resuscitation, and mortality among patients with community-acquired sepsis and septic shock.Design, Setting, and ParticipantsA cohort study was conducted of adult patients hospitalized in an integrated health care system from January 1, 2013, to December 31, 2015, with community-acquired sepsis and preexisting assessment of cardiac function. Follow-up occurred through July 1, 2016. Data analyses were performed from November 1, 2020, to August 8, 2022.ExposuresPreexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis.Main Outcomes and MeasuresMultivariable models were adjusted for patient factors and sepsis severity and clustered at the hospital level to generate adjusted odds ratios (aORs) and 95% CIs. The primary outcome was the administration of 30 mL/kg of intravenous fluid within 6 hours of sepsis onset. Secondary outcomes included in-hospital mortality, intensive care unit admission, rate of invasive mechanical ventilation, and administration of vasoactive medications.ResultsOf 5278 patients with sepsis (2673 men [51%]; median age, 70 years [IQR, 60-81 years]; 4349 White patients [82%]; median Sequential Organ Failure Assessment score, 4 [IQR, 3-5]), 884 (17%) had preexisting HFrEF, and 2291 (43%) met criteria for septic shock. Patients with septic shock and HFrEF were less likely to receive guideline-recommended intravenous fluid than those with septic shock without HFrEF (96 of 380 [25%] vs 699 of 1911 [37%]; P &lt; .001), but in-hospital mortality was similar (47 of 380 [12%] vs 244 of 1911 [13%]; P = .83). In multivariable models, HFrEF was associated with a decreased risk-adjusted odds of receiving 30 mL/kg of intravenous fluid within the first 6 hours of sepsis onset (aOR, 0.63; 95% CI, 0.47-0.85; P = .002). The risk-adjusted mortality was not significantly different among patients with HFrEF (aOR, 0.92; 95% CI, 0.69-1.24; P = .59) compared with those without, and there was no interaction with intravenous fluid volume (aOR, 1.00; 95% CI, 0.98-1.03; P = .72).Conclusions and RelevanceThe results of this cohort study of patients with community-acquired septic shock suggest that preexisting HFrEF was common and was associated with reduced odds of receiving guideline-recommended intravenous fluids.

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“…Clinical reasoning suggests underlying cardiac dysfunction of HF will worsen outcomes in a hemodynamically unstable state such as sepsis/septic shock, and data support this hypothesis, especially in HFrEF. 11 –13 Alon et al revealed a mortality increase in HF patients admitted for sepsis compared to patients without HF admitted for sepsis (51% vs 41%; P = .015). 13 A retrospective review of 174 patients (87 with HFrEF and 87 without HFrEF) presenting with sepsis showed HFrEF conferred higher in-hospital mortality (57.5% vs 34.5%; P = .002).…”

Section: Methodsmentioning

confidence: 98%

“…11 Ishak Gabra et al evaluated patients with sepsis and preexisting HFrEF and HFpEF and observed trends toward increased mortality. 12 Neither HFrEF (odds ratio [OR]: 1.88; P = .06) nor HFpEF (OR: 1.56; P = .25) were statistically associated with increased 28-day mortality when adjusted for severity of illness, but HFrEF was associated with increased new-onset arrhythmias (52% vs 23%; P = .0001). 12 Prabhu et al observed increased mortality among patients with sepsis with EF <50%, wherein 44% (n = 14/32) of nonsurvivors had depressed EF compared to 12% (n = 4/34) of survivors ( P = .005).…”

Section: Methodsmentioning

confidence: 99%

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

Jones

Smith

Tuyl

et al. 2020

J Intensive Care Med

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Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

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Outcomes of Patients With Chronic Heart Failure and Septic Shock

Cited by 5 publications

References 0 publications

Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study

Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

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