The pathophysiology of acute heart failure—Is it all about fluid accumulation?

Cotter, Gad; Felker, G. Michael; Adams, Kirkwood F.; Milo-Cotter, Olga; O’Connor, Christopher M.

doi:10.1016/j.ahj.2006.02.038

Cited by 172 publications

(106 citation statements)

References 52 publications

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“…First, episodes with primary diagnosis codes for heart failure and pulmonary edema were included, along with episodes with a primary diagnosis code for fluid overload. The relationship between fluid overload and heart failure is complex, with each exacerbating the other (9,11). Details available in Medicare claims data do not allow for clean separation of cases in which fluid overload was the initial condition resulting in exacerbation of heart failure versus cases in which changes in heart function resulted in fluid overload.…”

Section: Discussionmentioning

confidence: 99%

Hospital Treatment for Fluid Overload in the Medicare Hemodialysis Population

Arneson

Liu

Qiu

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: Fluid overload in hemodialysis patients sometimes requires emergent dialysis, but the magnitude of this care has not been characterized. This study aimed to estimate the magnitude of fluid overload treatment episodes for the Medicare hemodialysis population in hospital settings, including emergency departments.Design, setting, participants, & measurements: Point-prevalent hemodialysis patients were identified from the Centers for Medicare and Medicaid Renal Management Information System and Standard Analytical Files. Fluid overload treatment episodes were defined by claims for care in inpatient, hospital observation, or emergency department settings with primary discharge diagnoses of fluid overload, heart failure, or pulmonary edema, and dialysis performed on the day of or after admission. Exclusion criteria included stays >5 days. Cost was defined as total Medicare allowable costs for identified episodes. Associations between patient characteristics and episode occurrence and cost were analyzed.Results: For 25,291 patients (14.3%), 41,699 care episodes occurred over a mean follow-up time of 2 years: 86% inpatient, 9% emergency department, and 5% hospital observation. Heart failure was the primary diagnosis in 83% of episodes, fluid overload in 11%, and pulmonary edema in 6%. Characteristics associated with more frequent events included age <45 years, female sex, African-American race, causes of ESRD other than diabetes, dialysis duration of 1 to 3 years, fewer dialysis sessions per week at baseline, hospitalizations during baseline, and most comorbid conditions. Average cost was $6,372 per episode; total costs were approximately $266 million.Conclusions: Among U.S. hemodialysis patients, fluid overload treatment is common and expensive. Further study is necessary to identify prevention opportunities.

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Section: Discussionmentioning

confidence: 99%

Hospital Treatment for Fluid Overload in the Medicare Hemodialysis Population

Arneson

Liu

Qiu

et al. 2010

Clinical Journal of the American Society of Nephrology

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“…As with the DSL-mortality association, strong biologic basis for deleterious consequences of greater IDWG does exist. Chronic volume overload promotes maladaptive cardiac structural changes (e.g., left ventricular hypertrophy and fibrosis) through direct activation of the mammalian target of rapamycin pathway (26-28) and through upregulation of the sympathetic nervous system and renin-angiotensin-aldosterone pathways (29,30). This, in turn, distorts cardiac conduction pathway architecture and predisposes patients to arrhythmias and sudden cardiac death (18)(19)(20)(21)(22).…”

Section: Discussionmentioning

confidence: 99%

Disentangling the Ultrafiltration Rate–Mortality Association

Flythe

Curhan

Brunelli

2013

Clinical Journal of the American Society of Nephrology

103

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SummaryBackground and objectives Rapid ultrafiltration rate is associated with increased mortality among hemodialysis patients. Ultrafiltration rates are determined by interdialytic weight gain and session length. Although both interdialytic weight gain and session length have been linked to mortality, the relationship of each to mortality, independent of the other, is not adequately defined. This study was designed to evaluate whether shorter session length independent of weight gain and larger weight gain independent of session length are associated with increased mortality.Design, setting, participants, & measurements Data were taken from a national cohort of 14,643 prevalent, thriceweekly, in-center hemodialysis patients dialyzing from 2005 to 2009 (median survival time, 25 months) at a single dialysis organization. Patients with adequate urea clearance and delivered dialysis session $240 and ,240 minutes were pair-matched on interdialytic weight gain (n=1794), and patients with weight gain #3 and .3 kg were pair-matched on session length (n=2114); mortality associations were estimated separately.Results Compared with delivered session length $240, session length ,240 minutes was associated with increased all-cause mortality (adjusted hazard ratio [95% confidence interval], 1.32 [1.03 to 1.69]). Compared with weight gain #3, weight gain .3 kg was associated with increased mortality (1.29 [1.01 to 1.65]). The associations were consistent across strata of age, sex, weight, and weight gain and session length. Secondary analyses demonstrated dose-response relationships between both and mortality.Conclusions Among patients with adequate urea clearance, shorter dialysis session length and greater interdialytic weight gain are associated with increased mortality; thus, both are viable targets for directed intervention.

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“…When the absorptive capabilities of the alveoli cells are overwhelmed, pulmonary congestion occurs. 9 Further, in acute decompensated heart failure, normal reflexes stimulated by increased atrial pressure are blunted by reflexes initiated in the high-pressure arterial circulation. For example, an increase in total blood volume associated with decompensated heart failure prompts activation of the reninangiotensin-aldosterone system, leading to production of angiotensin II.…”

Section: Pathophysiology Of Hypervolemiamentioning

confidence: 99%

“…4 In order to compensate, total blood volume is increased by expansion of blood volume in the venous circulation and systemic vascular resistance (afterload) increases. 9 Increased afterload combined with impaired systolic performance also leads to an acute increase in left ventricular enddiastolic pressure. An acute increase in left ventricular end-diastolic and pulmonary venous pressures causes an increase of pressure in the alveoli.…”

Section: Pathophysiology Of Hypervolemiamentioning

confidence: 99%

Fluid Management Strategies in Heart Failure

Albert

2012

Critical Care Nurse

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In patients with chronic heart failure, fluid retention (or hypervolemia) is often the stimulus for acute decompensated heart failure that requires hospitalization. The pathophysiology of fluid retention is complex and involves both hemodynamic and clinical congestion. Signs and symptoms of both hemodynamic and clinical congestion should be assessed serially during hospitalization. Core heart failure drug and cardiac device therapies should be provided, and ultrafiltration may be warranted. Critical care, intermediate care, and telemetry nurses have roles in both assessment and management of patients hospitalized with acute decompensated heart failure and fluid retention. Nurse administrators and managers have heightened their attention to fluid retention because the Medicare performance measure known as the risk-standardized 30-day all-cause readmission rate after heart failure hospitalization can be attenuated by fluid management strategies initiated by nurses during a patient’s hospitalization.

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The pathophysiology of acute heart failure—Is it all about fluid accumulation?

Cited by 172 publications

References 52 publications

Hospital Treatment for Fluid Overload in the Medicare Hemodialysis Population

Hospital Treatment for Fluid Overload in the Medicare Hemodialysis Population

Disentangling the Ultrafiltration Rate–Mortality Association

Fluid Management Strategies in Heart Failure

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